Private Health Insures, like Aetna, Cigna, Wellcare and United Healthcare create the these plans but the Centers for Medicare Services (CMS) regulates them.
What Medicare Advantage Plans provide:
Medicare Advantage Plans are must to provide the same benefits that Medicare Parts A and B also provide.
MA Plans may also offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs, though, there is no coverage for hospice care as there is no requirement to do so.
Most MA Plans may also include Medicare prescription drug coverage (Part D) and the coverage is determined by the private health insurer and the the type of plan that is being offered.
The costs of Medicare Advantage Plans:
Premiums:
Everyone who enrolls into a Medicare Advantage Plan still has to meet the monthly Medicare Part B premium and some MA Plans also come with a monthly premium too, but the majority do not.
Please note that there are some MA Plans that do rebate or “giveback” a portion of the Medicare Part B. These MA Plans that do may have less benefits or higher out-of-pocket costs though.
Annual Deductible:
The Annual Deductible is specifically for Part D or prescription drug coverage and follows the regulations set by CMS.
In 2025 the maximum Annual Deductible per plan for drug coverage is $590.00 and it it is up to the private healt insurer to decide the amount.
Maximum Out Of Pocket Cost (MOOP)
The MOOP is the maximum amount you would pay out-of-pocket for healthcare services that a Medicare Advantage Plan covers during a calendar year. Once this limit is reached the MA Plan will 100% of the costs for covered services.
In 2025 the average MOOP is $5,316 for the year, but keep in mind there are plenty of MA Plans that have a much lower MOOP amount too.
Type of Medicare Advantage Plans;
Each Medicare Advantage Plans has distinct features that cater to different healthcare needs and preferences and there are 6 different types that you choose from, which are:
1. Medicare Advantage HMO (Health Maintenance Organization)
- Network: You must use doctors, hospitals, and providers within the plan’s network (except for emergencies or urgent care).
- Primary Care Physician (PCP): Usually required. Referrals from your PCP are typically needed to see specialists.
- Out-of-Network Coverage: Limited or no coverage, except in emergencies.
- Cost: Generally lower premiums and out-of-pocket costs compared to other plan types.
2. Medicare Advantage HMO-POS (Health Maintenance Organization – Point of Service)
- Network: Similar to HMO plans, but with some flexibility to go out-of-network for certain services.
- Primary Care Physician (PCP): Usually required.
- Out-of-Network Coverage: Covered for specific services, but at a higher cost.
- Cost: Typically higher premiums than regular HMOs but lower than PPOs.
3. Medicare Advantage PPO (Preferred Provider Organization)
- Network: Offers more flexibility. You can use providers in or out of the network, though staying in-network costs less.
- Primary Care Physician (PCP): Not required.
- Referrals: Not needed to see specialists.
- Cost: Higher premiums and out-of-pocket costs compared to HMOs but with greater flexibility.
4. Medicare Advantage Regional PPO (Preferred Provider Organization)
- Network: Operates similarly to standard PPOs but covers larger geographical areas (regions).
- Primary Care Physician (PCP): Not required.
- Referrals: Not required to see specialists.
- Out-of-Network Coverage: Covered, but out-of-pocket costs are higher.
- Focus: Designed to offer broad access to services across larger rural or underserved areas.
- Cost: May have cost-sharing requirements structured to incentivize in-network care but provide flexibility for wide coverage.
5. Medicare Cost Plans
- Network: Use any doctor or hospital that accepts Medicare. In-network care may have lower costs.
- Primary Care Physician (PCP): Not required.
- Out-of-Network Coverage: You can use Original Medicare for out-of-network services.
- Cost: Premiums and costs vary, and these plans are less common than Medicare Advantage plans.
6. Medicare PFFS (Private Fee-for-Service)
- Network: Flexibility to see any Medicare-approved provider who accepts the plan’s payment terms. Some plans have networks for lower costs.
- Primary Care Physician (PCP): Not required.
- Referrals: Not needed.
- Cost: Costs depend on the plan and services. These plans may have higher out-of-pocket expenses.
Key Considerations
- Coverage: HMO plans are restrictive but cost-effective; PPO and PFFS plans offer flexibility but are more expensive.
- Provider Choice: If seeing out-of-network providers is important, PPO or PFFS plans are better options.
- Cost: HMOs generally have the lowest costs, while PPOs and PFFS plans may have higher premiums or co-pays.
- Location: Some plans are only available in specific areas.
When choosing any Medicare Advantage Plan, consider your healthcare needs, budget, and the level of provider flexibility. The key is to find an MA Plan that suits your budget, bit more importantly will allow you access to your physicians.
