Medicare Advantage

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Medicare Advantage Basics

Seniors typically have two options for core Medicare benefits: Original Medicare (which can be paired with a Medicare Supplement plan) or Medicare Advantage (Part C). Medicare Advantage plans are all-in-one solutions offered by private insurers. As of 2025, one in three Medicare beneficiaries enrolled in a Medicare Advantage plan.

What Medicare Advantage Covers

Medicare Advantage plans, offered by private insurance companies, are required to cover all services included in Medicare Part A (hospital insurance) and Part B (medical insurance), except for hospice care, which remains covered by Original Medicare. Beyond these basic services, many MA plans offer additional benefits, including:

• Prescription Drug Coverage (Part D): Most MA plans include integrated prescription drug coverage, eliminating the need for a separate Part D plan.
  
  

• Dental, Vision, and Hearing Services: Many plans provide coverage for routine dental check-ups, vision exams, and hearing aids.
  
  

• Wellness Programs: Additional benefits such as gym memberships, nutritional counseling, and wellness classes are often included.
  
  

It's important to note that the specific benefits and coverage details can vary by plan and may change annually. Beneficiaries should review their plan's Annual Notice of Change to stay informed about any modifications.

Unlike Medicare Supplement plans, Medicare Advantage plans may also help with out-of-pocket costs, but benefits and networks change yearly. Beneficiaries can review and switch plans during Medicare’s Annual Enrollment Period (AEP).

Types of Medicare Advantage Plans

Health Maintenance Organization (HMO) – Requires members to use a network of providers; referrals needed for specialists. Most common plan type (63% of enrollees).

HMO Point of Service (HMO-POS) – Similar to HMOs but allows limited out-of-network coverage at higher costs.

Preferred Provider Organization (PPO) – Allows visits to any provider, but using in-network doctors is more affordable. Typically higher premiums than HMOs.

Special Needs Plans (SNPs) – Tailored for individuals with specific conditions, dual-eligibility for Medicare & Medicaid, or those living in institutions.

Private Fee-For-Service (PFFS) – May or may not have provider networks. Costs and payment terms are set by the insurer.

Medicare Savings Account (MSA) – Combines a high-deductible health plan with a medical savings account funded by Medicare.

Comparing & Enrolling in a Medicare Advantage Plan

Choosing the right plan depends on your budget, health needs, and preferred providers. Medicare’s Star Rating System (1 to 5 stars) helps assess plan quality.

Enrollment Periods:

• Initial Enrollment Period (IEP): When first eligible for Medicare.

• Annual Open Enrollment (Oct. 15 - Dec. 7): Switch or enroll in a new plan.

• Special Enrollment Period (SEP): Triggered by life events like moving or losing coverage.

Costs of Medicare Advantage

• Plan Premiums: Vary by provider; some plans have $0 premiums, while others include additional benefits for a fee.

• Part B Premium: The standard monthly premium for Medicare Part B has increased to $185.00 in 2025, up from $174.70 in 2024. Additionally, the annual deductible for Part B beneficiaries has risen to $257, an increase from $240 in 2024. .

• Copays & Coinsurance: Costs for services like lab work, ambulance rides, and x-rays depend on the plan.

• Out-of-Pocket Maximums: Medicare Advantage plans are required to set an annual limit on beneficiaries' out-of-pocket expenses for services covered under Medicare Parts A and B. For 2025, the maximum allowable limit is $9,350. However, individual plans may choose to set lower limits. It's important to note that this out-of-pocket maximum does not include expenses related to prescription drugs covered under Part D; those costs are addressed separately. .

• Out-of-Pocket Drug Cost Cap:

• A major enhancement in 2025 is the implementation of a $2,000 annual cap on out-of-pocket prescription drug costs for beneficiaries enrolled in Medicare Part D plans, including those integrated into Medicare Advantage. This change aims to reduce the financial burden on beneficiaries who require high-cost medications.

Is Medicare Advantage Right for You?

Medicare Advantage may be a cost-effective option for individuals who prefer an all-in-one plan and are comfortable with a provider network. However, those who travel frequently or require ongoing specialized care may benefit from Original Medicare with a Supplement plan instead.