What is Medicare Advantage (Part C)?

Medicare Advantage (Part C) is a private alternative to Original Medicare. A private insurer contracts with CMS to deliver your Medicare benefits in a single plan that bundles Part A (hospital), Part B (medical), and usually Part D (drugs). About half of all Medicare beneficiaries are now in Medicare Advantage.

MA plans must cover everything Original Medicare covers. They use provider networks. They have an annual in-network out-of-pocket maximum. They typically include some supplemental benefits like dental, vision, or hearing.

Three main differences. One: structure. MA bundles Parts A, B, and usually D into one plan. Original Medicare keeps them separate, and you usually add a Medigap supplement plus a standalone Part D plan.

Two: networks. MA plans use HMO or PPO networks. Original Medicare lets you see any provider in the U.S. that accepts Medicare.

Three: out-of-pocket costs. MA plans have an annual in-network out-of-pocket maximum. Original Medicare alone has no annual cap on what you pay — that's part of why most people on Original add a Medigap.

Most do. The version that includes drugs is called MAPD. The version without drugs is called MA-only. If you're considering an MA-only plan, you usually have to add a separate Part D plan to avoid the Part D late-enrollment penalty.

With one exception. Some MA-only plans are designed for people who already have other creditable drug coverage — like through the VA. Make sure you understand whether your other coverage counts as creditable before you skip Part D.

A Special Needs Plan is a type of Medicare Advantage plan limited to specific groups of people. There are three categories.

C-SNPs (Chronic Condition SNPs) serve people with qualifying chronic conditions — diabetes, heart failure, end-stage renal disease, and others. D-SNPs (Dual-Eligible SNPs) serve people on both Medicare and Medicaid. I-SNPs (Institutional SNPs) serve people in nursing homes or with comparable care needs at home.

SNPs are required to coordinate care more tightly than a standard MA plan. Whether one fits your situation depends on your specific condition and where you live.

An HMO (Health Maintenance Organization) generally requires you to use providers in the plan's network and may require referrals from a primary care provider for specialists. Out-of-network care is usually not covered except for emergencies.

A PPO (Preferred Provider Organization) covers in-network care at a lower cost share and out-of-network care at a higher cost share. Referrals are usually not required. PPOs cost more but give more flexibility.

There are also less common types — PFFS (Private Fee-for-Service), HMO-POS, and MSA (Medical Savings Account). Most people end up choosing between an HMO and a PPO.

Most Medicare Advantage plans include some level of dental, vision, and hearing. Almost none of them include unlimited dental, vision, and hearing. The TV ads show the benefit. The Evidence of Coverage shows the cap.

Typical caps run a few hundred to a couple thousand dollars per year, depending on the plan and benefit. Read the EOC. Don't pick a plan based on the dental ad alone.

All Medicare Advantage plans must have an annual in-network out-of-pocket maximum. CMS sets the ceiling each year. For 2026, the in-network ceiling is around $9,250. PPO plans that cover out-of-network care have a higher combined ceiling, around $13,900.

Most plans set their actual maximum below the ceiling — some well below. Once you hit your plan's maximum, the plan pays 100% of covered Part A and B services for the rest of the year. Original Medicare alone has no such cap, which is why most people on Original add a Medigap supplement.

CMS publishes Star Ratings for every Medicare Advantage and Part D plan once a year. The scale runs from 1 star (poor) to 5 stars (excellent). Ratings are based on dozens of measures — quality of clinical care, member experience, customer service, complaints, and more.

There's also a small enrollment perk for top-rated plans: people can use a 5-Star Special Enrollment Period to switch into a 5-star MA or Part D plan once between Dec 8 and Nov 30 of the next year, outside of the normal enrollment windows.

Yes, but only in specific windows. The Annual Enrollment Period runs Oct 15 – Dec 7 and lets you switch to any other MA plan or back to Original Medicare. The MA Open Enrollment Period runs Jan 1 – Mar 31 and gives you one switch — MA-to-MA, or MA-back-to-Original (with a Part D plan).

Here's what catches people. If you go back to Original Medicare and want to add a Medigap supplement, you usually have to pass medical underwriting outside of guaranteed-issue windows. You can be denied based on your health. Before you switch, check whether you have a guaranteed-issue right — SHIP can walk you through it.

Hang up. CMS Medicare Communications and Marketing Guidelines (MCMG) prohibit cold-call solicitation for Medicare Advantage and Part D. A real Medicare advisor does not call you out of the blue.

Don't give your Medicare number, date of birth, or Social Security number. Don't agree to a "benefit review" or "plan upgrade" over an unsolicited call. If you want to report it, call 1-800-MEDICARE.