What Is Medicare Advantage (Part C)?

Medicare Advantage, also called Part C, is a private plan that delivers your Part A and Part B benefits, usually with drug coverage, through a network of doctors and hospitals. It fits people who want one card, one plan, and often extras like dental. The mistake people make: choosing it for the extras and never checking the network again.

You must still be enrolled in Original Medicare, Parts A and B, and you still pay the Part B premium, $202.90 per month in 2026 for most people.* Instead of Medicare paying your doctors directly, it pays a private company to cover you, and that company’s plan delivers your benefits. Overview: Medicare Advantage plans.

The plan must cover everything Original Medicare covers; hospice stays with Original Medicare. Most plans include Part D, and many add benefits Original Medicare does not offer.

What you give up is the open door. Original Medicare lets you see any provider who accepts Medicare; an Advantage plan asks you to use its network and manages care with copays, referrals, and prior authorization. Neither path is universally better. The mistake is choosing Advantage without knowing the trade.

Key point: an Advantage plan is a one-year contract. Premiums, copays, the drug list, and the network can change every January 1. So can your plan, during the enrollment periods below.

This guide is educational, not personalized advice. Your doctors, prescriptions, health, budget, and where you spend the year decide what fits you.

How an Advantage Plan Works Day to Day

The network

Every plan has a list of doctors, hospitals, labs, and pharmacies it works with. Your doctors and hospital either are or are not on it. Check it by name, every year, because doctors and plans part ways.

At an annual review in our offices, a man in his 70s learned that the specialist he had seen for years would not be in his plan’s network the following January. Nothing in his life had changed; the plan’s contract with the doctor had. He moved to a plan that included every doctor on his list. The teaching point: the network you signed up with is not the network you will have forever. Check every doctor, every fall.

Copays and the annual limit

Instead of Medicare’s deductibles and usual 20% coinsurance,* an Advantage plan charges set copays: one for a primary care visit, another for a specialist, a daily amount for a hospital stay. They are in the plan’s Summary of Benefits and differ plan to plan.

Every plan also sets an annual limit on what you pay in-network for covered medical services, and Medicare caps how high that limit can be: no plan’s in-network limit may exceed $9,250 in 2026.* Once you reach it, the plan pays covered in-network care in full for the rest of the year. Original Medicare alone has no such limit, and that protection is one of the honest arguments for Advantage: Medicare Advantage costs.

Referrals and prior authorization

Many plans require a referral to see a specialist, and the plan’s approval before certain tests, procedures, or medications. A man in his 70s on an HMO called us after weeks of trying to get a referral to a neurologist. He was not being denied care. He was stuck in a process nobody had explained, and our office worked it through with the plan and the doctor. The teaching point: on an Advantage plan, know who has to say yes before you can go. When a plan says no, you have appeal rights: Medicare claims and appeals.

Drug coverage inside the plan

Most Advantage plans include Part D. The plan’s drug list, called a formulary, and its pharmacy network decide what your prescriptions cost. For 2026, the Part D out-of-pocket cap is $2,100 and the maximum Part D deductible is $615,* and those limits apply inside an Advantage plan just as they do to a standalone drug plan. Check prescriptions against the formulary before choosing, or the choice is a guess.

HMO vs PPO (and the Other Types)

The two letters that matter most are HMO and PPO; Medicare explains each: HMO plans and PPO plans.

Source: medicare.gov plan type pages

Special Needs Plans serve people with certain chronic conditions, people who qualify for both Medicare and Medicaid, or people in certain institutions: Special Needs Plans.

One rule deserves its own paragraph. Every Advantage plan must cover emergency and urgently needed care anywhere in the United States, in or out of network. A woman in her 70s called about a bill after her husband was admitted to an out-of-network hospital from its emergency room. The emergency was covered. The bill came from what happened after he was stabilized and admitted, when a plan may expect a transfer to an in-network hospital. We helped her appeal. The teaching point: the emergency is covered everywhere. What comes after it follows the plan’s rules. Know them before you need them.

The Extra Benefits, Honestly

This is where Advantage plans earn their attention. Many include some combination of routine dental, vision, hearing, a fitness membership, an over-the-counter allowance, and transportation. Original Medicare covers none of those, and neither does a Supplement, which only fills gaps in what Original Medicare covers.

Those benefits are real. They are also the part that changes most easily year to year. A dental benefit can be a cleaning allowance or a real network with real limits; a hearing benefit can be a discount or a copay. The Summary of Benefits says which.

A woman in her late 60s from the Valley came in paying a Supplement premium she resented. An Advantage plan with no premium of its own, plus dental and vision, looked like the obvious move. We laid both out on the screen. The extras were real. So were the copays, the network, and the annual limit. And a Supplement is close to a one-way door: if she left it and later wanted it back, she would face health questions. She decided with all of that in front of her. The teaching point: an extra benefit is a reason to look. It is not a reason to skip the rest of the comparison.

What Changes on January 1

Every fall, by September 30, your plan sends an Annual Notice of Change.* It lists what changes January 1: premium, copays, formulary, pharmacy and doctor networks, extras. Read it. Most of the trouble we see in January started with an envelope that went in a drawer.

Some years the letter says something bigger: the plan will not be offered next year. Every October our phones carry the same worried sentence: “I got a letter that says my plan will not be offered.” A woman in her early 70s called the day hers arrived. What we told her applies to anyone:

• You will not be left without Medicare. Original Medicare continues; the plan delivering it ends.
• Doing nothing is a decision. Take no action and Medicare enrolls you in Original Medicare on January 1 when the plan ends,* with no drug coverage unless you join a Part D plan and no Supplement unless you buy one.
• You have two paths. Another Advantage plan during the Annual Enrollment Period, or Original Medicare with a Supplement and a Part D plan. A plan leaving Medicare gives you a guaranteed issue right to buy Plan A, B, D, G, K, or L (and Plan C or F if you were eligible for Medicare before January 1, 2020), as long as you return to Original Medicare and apply no later than 63 days after the plan coverage ends; the company must sell to you, must cover your pre-existing conditions, and cannot charge more for your health.*

The teaching point: a non-renewal letter is not an emergency. It is a deadline. Treat it like one.

Three facts hold even when your plan is renewed. Your Part B premium still comes out of your Social Security check, $202.90 per month in 2026 for most people. Higher-income households pay an IRMAA surcharge on top, starting when income from two years earlier was above $109,000 single or $218,000 married filing jointly, and no Advantage plan removes it. And the drug side resets to the 2026 rules, including the $2,100 out-of-pocket cap.*

When You Can Join, Switch, or Leave

Advantage plans have seasons; joining a plan has Medicare’s rules. In plain English:

• When you first get Medicare. Your Initial Enrollment Period is 7 months: the 3 months before the month you turn 65, your birthday month, and the 3 months after.* See turning 65.
• Every fall. The Annual Enrollment Period, October 15 to December 7, is when anyone can join, switch, or drop an Advantage plan, with the change taking effect January 1.* The workshop on October 2, 2026 is built around it.
• Early in the year. If you are already in an Advantage plan, the Medicare Advantage Open Enrollment Period, January 1 to March 31, allows one change: switch to another Advantage plan, or drop it and return to Original Medicare, adding a separate Part D plan if you want one. It cannot be used to move from Original Medicare into an Advantage plan, and the change takes effect the first of the month after the plan gets your request.*
• When life changes. Special Enrollment Periods open when you move out of your plan’s service area (2 full months after the move), when you leave employer or union coverage, including COBRA (2 full months after the month it ends), when your plan’s contract is not renewed (December 8 through the last day of February), and in other listed situations. Leaving a job after 65, you have 8 months after employment or group coverage ends to enroll in Part B without penalty, and COBRA does not count as employer coverage.* Read leaving employer coverage.

The one-way door

Joining an Advantage plan never involves health questions. Leaving it for a Supplement usually does. Your one guaranteed 6-month Supplement window starts the first month you are 65 or older and enrolled in Part B, and it does not come back. A trial right protects you if you joined an Advantage plan when you were first eligible for Medicare at 65, or dropped a Supplement to join one for the first time, and you leave within the first 12 months; guaranteed issue rights also apply when your plan leaves you, with a 63-day deadline. Outside those, the Supplement company can ask about your health and can say no. And switching is allowed, not required. A review that ends in “stay” is still a review.

Medicare Advantage vs Medicare Supplement

The Supplement guide tells the other half of this story.

Source: compare Original Medicare and Medicare Advantage

Questions to Answer Before You Choose

No plan is right for everyone. The right one answers these:

1. Is every doctor I use in the network, by name? Primary care, every specialist, and the hospital you would want.
2. Is every prescription on the formulary, at my pharmacy? Including the tier it sits on.
3. What is the annual in-network limit, and could I fund it in a bad year?
4. HMO or PPO? A referral process, or paying more for the option to go outside the network?
5. Where will I be in February? Months in another state change the network question.
6. If I leave a Supplement for this, do I understand that coming back may mean health questions?

That is how a Certified Medicare Planner® works: doctors and prescriptions loaded before any recommendation, every plan we represent in your ZIP code on the screen whether or not we are paid on it, a Stay-or-Go Analysis™ if you have employer coverage, a written summary, and a review every year. It is our own standard, not a government credential; read what it promises you.

Start with how Medicare works, or, if you are already in a plan, already on Medicare. The workshop on October 2, 2026 covers Advantage and Supplement side by side in an hour: reserve a seat.