What is Medicare Advantage Exactly?

Medicare Advantage is a privately managed alternative to Original Medicare. A Medicare Advantage plan covers all of the services of Original Medicare, and usually includes Part D (drug coverage) as well. A Medicare Advantage plan may even offer additional services that Original Medicare does not cover, such as dental, hearing or vision coverage. Medicare Advantage plans are often confused with Medicare Supplements (Medigap) but they are very different and have different advantages and disadvantages associated with each.


Here are some of the basics about Medicare Advantage. The first thing you should know is that there are different types of Medicare Advantage plans.


  • Health Maintenance Organization (HMO) plans – HMOs require their members to see doctors, other healthcare providers, or hospitals that are in the plan’s network, unless it is for an emergency or urgent care. This means that if a member of an HMO plan decides to voluntarily go to a hospital or doctor that is not within the plan’s network, he or she will be responsible for all the costs associated with medical services received. Therefore it is very important that before you enroll in an HMO plan, you verify that the doctors and hospitals that you currently use are in network. HMOs are the most common Medicare Advantage plans available.


  • Preferred Provider Organization (PPO) plans – PPOs are very similar to HMO plans. Both utilize networks of doctors, hospitals and other healthcare providers. However PPO plans do allow for members of their plan to go to hospitals and doctors outside of the plan’s network. If a plan member chooses to see an out-of-network provider the member’s cost sharing will be higher than if they saw a provider that was in the plan’s network.


  • Private-Fee-for-Service (PFFS) plans – PFFS plans are similar to Original Medicare in that you can generally go to any doctor, other health care provider, or hospital as long as they accept the plan’s payment terms. The plan determines how much it will pay health care providers and hospitals, and how much you must pay when you get care.


  • Special Need Plans (SNPs) – SNPs provide focused and specialized health care for specific groups of people, like those who have both Medicare and Medicaid, live in a nursing, or have certain chronic medical conditions.


  • HMO Point-of-Service (HMOPOS) plans – These are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance.


  • Medical Savings Account (MSA) plans – these plans combine a high deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your heath care services during the year. MSA plans do not offer Medicare drug coverage. If you want drug coverage, you have to join a Medicare Prescription Drug Plan. For more information about MSAs, visit to view the booklet “Your Guide to Medicare Medical Savings Account Plans.”


In order to join a Medicare Advantage plan you must have Medicare Parts A and B and live in the plan’s service area. People with End Stage Renal Disease (ESRD) generally can’t join a Medicare Advantage Plan.


In addition to your Part B premium, you may pay a monthly premium for the services included in a Medicare Advantage Plan. Some Medicare Advantage Plans have a $0 monthly premium. Each Medicare Advantage Plan has different premiums and costs for services, so it’s important to compare plans in your area and understand plan costs and benefits before enrolling.


Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you are enrolled in a Medicare Advantage Plan. With all types of Medicare Advantage Plans, you are always covered for emergency and urgent care. Medicare Advantage Plans must offer emergency coverage outside of the plan’s service area, but not necessarily outside of the U.S. (although many plans do). Many Medicare Advantage Plans offer extra benefits such as dental care, eyeglasses, or wellness programs like Silver Sneakers. Most Medicare Advantage Plans include Medicare prescription drug coverage, Part D. Plan benefits can change from yea to year. Each year in September, Medicare Advantage Plans send an Annual Notice of Change to all of its members. This notice informs plan members of all the changes to the plan that will take effect at the beginning of the next calendar year.


There is a lot to consider when shopping for a Medicare Advantage Plan. Health Enroller has licensed agents available to assist you with selecting the best plan for you. Our agents can verify whether or not your doctor is in network, your prescriptions are covered, and can explain many of the other plan’s out of pocket costs and benefits. Call us today at 1-844-680-7855 or shop for a Medicare Advantage Plan at

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