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Medicare Advantage has become increasingly popular, now covering nearly half of all Medicare beneficiaries. It's easy to see why: lower monthly premiums, extra benefits Medicare doesn't cover, and the simplicity of one card for all your healthcare needs.
But Medicare Advantage isn't right for everyone. There are trade-offs—primarily network restrictions and copays when you use services. Let me walk you through exactly how Medicare Advantage works, what it costs, and whether it might be the right choice for you.
Medicare Advantage (Part C) is an alternative way to get your Medicare benefits. Instead of getting coverage directly from the federal Medicare program, you receive all your benefits through a private insurance company that contracts with Medicare.
How it works: Medicare pays the insurance company a set amount per month to manage your care. The company provides all your Part A (hospital) and Part B (medical) coverage, typically includes Part D (prescriptions), and often adds extra benefits like dental, vision, and hearing.
Important: You're still in Medicare—you're just getting your benefits through a private plan instead of Original Medicare. You must continue paying your Part B premium ($202.90 in 2026).
How it works: Must use network doctors and hospitals except in emergencies. Require referrals from your primary care doctor to see specialists. No coverage for out-of-network care except emergencies.
Best for: People who stay local, don't travel often, and prefer coordinated care through a primary doctor. Typically offers the lowest out-of-pocket costs.
How it works: Can see out-of-network providers at higher cost. No referrals needed for specialists. Partial coverage when out of network.
Best for: People who want some flexibility while keeping costs moderate. Good balance between choice and affordability.
How it works: Tailored benefits for specific groups—people with both Medicare and Medicaid (Dual-eligible SNPs), people with chronic conditions like diabetes or heart disease (Chronic condition SNPs), or people in nursing homes (Institutional SNPs).
Best for: People with specific qualifying conditions or circumstances who need coordinated specialized care.
Required Coverage: All Part A (hospital) and Part B (medical) services that Original Medicare covers, including emergency and urgent care anywhere in the U.S.
Usually Included: Part D prescription drug coverage. Preventive care at $0 cost.
Extra Benefits Often Included: Routine dental (cleanings, exams, fillings), routine vision (eye exams, glasses allowance), routine hearing (exams, hearing aid allowances), fitness benefits (gym memberships), over-the-counter allowances ($40-150/quarter), transportation to appointments, telehealth visits, and meal delivery after hospital stays.
Important: Benefits vary significantly by plan. Always review the specific plan's Summary of Benefits.
Many plans cost $0 in additional premium beyond your Part B payment ($202.90). Some plans charge $20-100+ per month. Total monthly cost typically ranges from $203-$300.
One of the best features of Medicare Advantage: annual out-of-pocket maximums typically ranging from $3,000-$8,000. Once you reach this limit, the plan pays 100% for covered services for the rest of the year.
This is protection Original Medicare doesn't have. Even with the copays, you know your maximum annual exposure.
Before enrolling in a Medicare Advantage plan, verify your doctors are in the network.
Steps to confirm:
Warning: Provider directories aren't always accurate. Always call to confirm.
If your doctor drops out of your plan's network during the year, you typically have 90 days to find a new in-network doctor. You can also switch to another Medicare Advantage plan during a Special Enrollment Period, or switch to Original Medicare (though getting a Medicare Supplement may require medical underwriting).
Within the U.S.: Emergency and urgent care is covered nationwide. For routine care, it depends on your plan type. HMO plans typically only cover emergency/urgent care when traveling. PPO plans allow you to see out-of-network doctors at higher cost.
Outside the U.S.: Most plans provide no coverage abroad except emergency situations. If you travel internationally frequently, consider travel insurance or Original Medicare with a supplement that includes foreign travel coverage.
Some Medicare Advantage plans offer a Part B Giveback Benefit (also called Part B premium reduction). The plan pays part or all of your Part B premium, appearing as a credit on your Social Security check.
Example: Standard Part B premium is $202.90. Plan gives back $100. Your net Part B cost is $102.90.
Trade-offs: Plans with giveback often have more limited networks, higher copays, or fewer extra benefits. We help you compare total costs—not just the premium reduction.
Medicare Advantage is often the best choice if you:
Want lower monthly premiums. Many $0 premium plans available. Pay only when you use services.
Desire all-in-one simplicity. One card, one plan. Don't want to coordinate multiple policies.
Live in one area year-round. Don't split time between states. Comfortable with network restrictions.
Value extra benefits. Dental, vision, hearing, fitness programs included.
Are generally healthy. Fewer doctor visits mean lower total costs. Out-of-pocket max protects against major events.
Have established local doctors. Your doctors are in the plan network. You prefer coordinated care.
Medicare Advantage offers an attractive package: lower monthly premiums, all-in-one coverage, extra benefits, and out-of-pocket protection. The trade-offs are network restrictions and copays when you use services. It's an excellent choice for people who stay local, want comprehensive benefits, and prefer simplicity.
At A&E Insurance Agency, we help you compare Medicare Advantage plans in your area, verify your doctors are in network, calculate your total annual costs based on your health needs, and review extra benefits across plans. We'll show you the top-rated options and help you choose coverage that fits your lifestyle and budget. Schedule a free consultation to explore your Medicare Advantage options.
