What Is Medicare Advantage, and Is It Right for You?

3. You won’t need to buy Medigap coverage with Medicare Advantage either. This private insurance works only with original Medicare to limit its out-of-pocket costs but has its own monthly premiums.

4. The government requires Medicare Advantage plans to limit your out-of-pocket costs each year. In 2026, that cap is $9,250 for in-network care, and $13,900 total for covered in-network and out-of-network services, but individual plans can set their maximums lower.

5. Your medical care can be more coordinated. Many Medicare Advantage plans require a primary care physician to be the supervisor for all the treatment you need, which isn’t true for original Medicare.

6. But people keep coming back to the idea of extras.

Nearly all Medicare Advantage plans offered some form of dental, hearing and vision coverage in 2026, a hallmark of the plans for at least the past six years. The percentage of plans with some fitness benefits has declined slightly during the same time but is still above 90 percent.

Cons. 1. The extras aren’t always used. About 3 in 5 Medicare Advantage enrollees left their dental or vision benefits on the table, and more than half didn’t tap their allocation for health supplies, according to a 2024 survey from the Commonwealth Fund, a New York–based nonprofit foundation that studies health care.

The extras that prospective enrollees are searching for — grocery cards and flex cards for health supplies — and that Medicare brokers and agents pitch in ads and phone conversations are available to only a small number of people with chronic conditions or dual eligibility for Medicaid.

2. You may face pressure from an insurance agent to sign up. That’s because Medicare Advantage plans pay these salesmen a higher commission than if you sign up for a standalone Part D plan and Medigap.

3. You’ll be restricted on the doctors and specialists you can go to. Both the HMOs and PPOs that are the foundation of Medicare Advantage plans require enrollees to stay in their provider networks to pay the lowest prices or even get coverage.

Some HMOs will require you to foot the entire bill for care outside their networks, except in an emergency. PPOs allow you to use services outside their networks, but the copayments you’ll pay up front, and coinsurance, often 20 percent of the charges billed to your plan, will cost more when you go elsewhere.

4. What attracted you to a plan could be gone next year.

Copays and coinsurance rates change. Doctor groups leave plans. Your favorite extra benefits may be dropped. Medications and the pharmacies you buy them from could disappear from your plan’s coverage lists.

Medicare Advantage is not a set-it-and-forget-it option. Watch for your plan’s annual notice of change, mailed every September, that details modifications effective in January and compare your plan with others being offered every year during open enrollment, Oct. 15 to Dec. 7.

5. As you need more care, you’ll probably have to jump through more hoops. Almost all Medicare Advantage enrollees are required to get prior authorization for some services, generally high-cost care such as from specialists or for chemotherapy.

Nearly 53 million prior authorization requests, 1.7 per person enrolled, were made in 2024, KFF says. Almost 8 percent were denied, but less than 12 percent were appealed.

Prior authorizations add time for approval or denial to the process and put an insurer between you and the expertise of your doctors. Studies indicate that prior authorization may hinder Medicare Advantage enrollees’ access to care, the federal Government Accountability Office says.

6. If you’re unhappy with Medicare Advantage after more than a year, you may have trouble leaving. Medigap, which helps pay for out-of-pocket costs you encounter with original Medicare, can be the roadblock.

Your first 12 months in Medicare Advantage are a trial period when you can leave your plan for original Medicare and either purchase supplemental insurance for the first time if you never had original Medicare or get the Medigap policy you had previously if the company still sells it.

States are allowed to make many of the rules around Medigap, so some are less stringent than federal law about when and under what circumstances a person can buy a policy without being asked health questions.

What does Medicare Advantage cover?

The federal government requires Medicare Advantage plans to cover the same services that Medicare Part A and Part B do, but the plans may have different deductibles and copayments. If a plan offers prescription coverage, it is the same as in a stand-alone Part D plan through original Medicare.

Medicare Advantage plans were originally designated as Part C, filling the gap between Part B and Part D in Medicare’s alphabet soup of coverage.

Because of the subsidies that insurers get from the federal government, plans try different combinations of additional benefits original Medicare doesn’t cover among the plans they offer. Plans from the same company may have different benefits, different deductibles and different provider networks.

Some Medicare Advantage plans provide additional coverage to people with chronic conditions. Provisions might include meal delivery or grocery allowance, shower grips and wheelchair ramps for your home, plus transportation to and from doctors’ offices.

What Medicare Advantage doesn’t cover

While Medicare Advantage plans cover more than original Medicare through their added benefits, you may find that expensive procedures not considered medically necessary won’t pass the prior authorization test.

Some are the same as what original Medicare won’t pay for:

• Cosmetic dental care
• Elective plastic surgery
• Laser eye surgery
• Long-term care
• Medicare care outside the United States with a few exceptions

Also, administrators for Medicare Advantage plans are unlikely to approve a procedure if a less expensive option is available. Some may require you to go through several steps without success before giving the OK for what you and your doctor preferred in the first place.

Getting an expensive brand-name drug OK’d for your use also probably will be a several-step process, called step therapy.

The costs you pay for Medicare Advantage

You must be enrolled in Medicare Part A, which is premium free if you or your spouse have worked 40 calendar quarters, and Part B, which has a monthly premium.

Part B premium. The standard premium is $202.90 in 2026, which the Medicare Trustees Report estimates will increase to $209.50 in 2027. You’ll pay this premium whether you’ve chosen original Medicare or Medicare Advantage.

About a third of Medicare Advantage plans give Part B premium refunds, an extra benefit that reduces the amount taken out of your Social Security or railroad retirement check for your Part B premium, KFF says. In 2026, almost a third of Medicare Advantage enrollees had chosen a plan with this feature, but the amount was most often less than $10 a month.

Plan premium. Two-thirds of Medicare Advantage plans charged no additional premium in 2026, KFF says. The average premium for all Medicare Advantage plans, including plans with no premium, was $15 a month.

Deductible. Not all plans require you to meet a deductible. Some apply the deductible to drug benefits but not medical benefits when a plan covers both.

The average monthly deductible in 2026 ranges from $0 to $34. The highest deductible a plan with prescription benefits is allowed to charge in 2026 is $615. 

Copays. Nearly three-fourths of Medicare Advantage plans had no up-front costs for primary care physician visits, according to a 2026 study published in the journal JAMA Health Forum. Copays for specialists and other services, such as emergency care, inpatient hospitalization and outpatient surgery, vary even for plans from the same insurance company.

Spending limits. The government requires Medicare Advantage plans to limit total copays, coinsurance and deductibles for what would be covered under Part A and Part B. It can’t exceed $9,250 for in-network care, and $13,900 total for covered in-network and out-of-network services in 2026.

The average cap for Medicare Advantage plan enrollees is $5,421 in-network and $9,825 for both in- and out-of-network combined, according to KFF. Drug costs have a separate limit, the same $2,100 cap for Part D plans in 2026, which will go up to $2,400 in 2027.

When to sign up for Medicare Advantage

You can look at plans during your initial enrollment period before you get your Medicare card. But you’ll need your Medicare number to sign up on Medicare’s Plan Finder.

While you can’t enroll in a Medicare Advantage plan at any time, you do have the chance to switch from original Medicare to Medicare Advantage during open enrollment every year. And if you have second thoughts, you can switch plans or switch back during Medicare Advantage open enrollment Jan. 1 to March 31 annually.

This story, originally published May 24, 2022, has been updated to include some of the pros and cons of Medicare Advantage as well as its most-offered extra benefits.