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Frequently Asked Questions

What is Medicare Advantage?

Medicare Advantage plans are health insurance plans offered by private health insurance companies approved by Medicare. Medicare Advantage health plans (such as HMOs and PPOs) are legally required to offer at least the
same benefits as Original Medicare but can include additional coverage as well, such as routine vision or dental benefits, health wellness programs, or prescription drugs.

What are the benefits of a Medicare Advantage plan?

The best benefit of a Medicare Advantage plan is that you can get your prescription drug benefits (Medicare Part D) included under the same plan, instead of having to enroll in a separate stand-alone Medicare Prescription Drug Plan. Also known as Medicare Advantage Prescription Drug plans, these plans give you the convenience of having your Medicare Part A, Part B, and Part D coverage through a single plan.

If you want prescription drug benefits, you should get it through a Medicare Advantage plan that includes this coverage; you shouldn’t enroll in a Medicare Prescription Drug Plan, which typically works with Original Medicare. Medicare Advantage plan costs and coverage details can vary depending on the insurance company and county that you live in.

Here are some more pros for Medicare Advantage plans:

Some insurance companies could offer a $0 premium for the Medicare Advantage plan.

Beyond the benefits that Original Medicare offers, Your Medicare Advantage plan may cover additional benefits that are not covered by Part A and Part B, such as vision or dental coverage.

Each plan comes with a maximum out-of-pocket limit on how much you will spend on health costs each year. Once that limit is reached, you will pay nothing for covered services.

Medicare Advantage Plan could have a different limit, and that amount may change each year.

Who is eligible for Medicare Advantage?

In order to be eligible for Medicare Part C, you must be enrolled in both parts of Original Medicare (Part A and Part B).

Once you have Medicare Part A and Part B, you are generally able to enroll in a Medicare Advantage plan, provided you live in the plan’s service area, and do not have end-stage renal disease (ESRD).

There are some exceptions where you may be able to enroll in a Medicare Advantage plan even if you have end-stage renal disease. For example, if you’re enrolling in a Special Needs Plan that targets beneficiaries with end-stage renal disease, you may be eligible to enroll in this type of Medicare Advantage plan. To learn more about other situations where you may be eligible for Medicare Part C if you have end-stage renal disease, you can contact Medicare at

1-800-MEDICARE (1-800-633-4227); 24 hours a day, seven days a week. TTY users should call 1-877-486-2048.

Those with other health insurance coverage (a union or employer-sponsored health plan, for example) should get more information about their existing coverage before enrolling in a Medicare Advantage plan. It is possible you could lose your existing coverage once you enroll in a Medicare Advantage plan. Furthermore, if you discontinue the other plan for Medicare Part C coverage, you may not be able to reinstate your original coverage if you change your mind. It is generally a good idea to check with your current benefits administrator before you enroll in another health-care plan. We help them practice their speaking, listening, reading, and writing without feeling they’re being taught.

What plan options do I have? What Providers are available?

The following are types of Medicare Advantage plans that may be available in your location:

• Health Maintenance Organization (HMO) plans:

These plans offer a network of doctors and hospitals that members are generally required to use to be covered. Because of this, HMOs tend to have strict guidelines, meaning that any visits and prescriptions are subject to the plan approval. If you use providers outside of the plan network, you may need to pay the full cost out of pocket (with the exception of emergency or urgent care). You generally need to get a referral from your primary care doctor to see a specialist.

• Preferred Provider Organization (PPO) plans:

Medicare Advantage PPO plans offer a network of doctors and hospitals for beneficiaries to choose from. Unlike an HMO, you have the option to receive care from health-care providers outside of the plan’s network, but you’ll pay higher out-of-pocket costs. Medicare Advantage PPOs don’t require you to have a primary care doctor, and you don’t need referrals for specialist care. • Private Fee-for-Service (PFFS) plans: This type of plan allows visits to any Medicare-approved

doctor or hospital, as long as the plan’s terms and conditions of payment are accepted by the provider. Keep in mind that you’ll need to find providers that contract with the plan each time you are receiving treatment.

• Special Needs Plans (SNPs):

These plans limit enrollment to beneficiaries who have certain chronic conditions, are institutionalized, or qualify for both Medicare and state Medicaid (also known as dual eligibility). Benefits, provider options, and prescription drugs are tailored to meet the needs of the plan’s enrollees.

• Medicare Medical Savings Account (MSA) plans:

These plans combine a high-deductible Medicare Advantage plan with a medical savings account. Every year, your MSA plan deposits money into a savings account that you can use to pay for medical expenses before you’ve reached the deductible. After you reach the deductible, your plan will begin to pay for Medicare-covered services. These plans don’t cover prescription drugs; if you want Medicare Part D coverage, you may enroll in a stand-alone Medicare Prescription Drug Plan.

How much does a Medicare Advantage plan cost?

With Medicare Advantage, each insurance company has the option to price its plans differently, although all Medicare Advantage plans must offer at least the same amount of coverage as Original Medicare (Part A & Part B).

Plans that offer additional coverage such as routine vision, dental, and prescription drug coverage may be more likely to charge higher out-of-pocket costs. Certain types of Medicare Advantage plans, such as Health Maintenance Organization (HMO) plans, may require that beneficiaries use in-network providers, or they will not cover the costs of services, with the exception of medical emergencies. In general, Medicare Advantage plans have lower cost-sharing than Original Medicare, but specific Medicare Part C costs will depend on the plan.

Noted earlier, the difference between Medicare Part C and Original Medicare is that all Medicare Advantage plans have a yearly out-of-pocket spending limit. Once you reach the plan limit (including the deductible), the Medicare Advantage plan covers 100% of covered medical services for the rest of the year. With Medicare Advantage plans, you have peace of mind knowing that there’s a cap to your annual medical costs.

Medicare Part B generally includes monthly premiums unless you qualify for low-income assistance. In addition to paying your Part B premium, you may also be responsible for paying a Medicare Advantage premium. Premiums can range from $0 and up depending on your plan. You may want to compare all available plan options in your area to find a plan with costs and benefits that meet your needs. Remember, even if your service area offers a Medicare Advantage plan with a $0 premium, this doesn’t mean that that plan won’t have other costs.

You’ll still need to pay the Medicare Part B premium, along with any co-payments,

coinsurance, or deductibles required by the Medicare Advantage plan.

• How much you pay for each service or doctor visit (copayment and/or coinsurance).

• Whether the plan has a yearly deductible that you must meet before it provides coverage.

• What type of services you require and how often you require them.

• Whether you enroll in a plan with additional benefits such as routine vision, dental, or prescription drug coverage.

• Your out-of-pocket prescription drug costs (if the plan includes this benefit).

• How much the plan’s maximum out-of-pocket limit is for covered medical services.

• Whether you will be required to receive care from in-network health-care providers or whether you can use non-network providers (usually with higher cost-sharing).

Medicare Advantage plans determine cost-sharing requirements for covered services, and each plan sets its own coinsurance percentages and terms. So it’s a good idea to shop around and compare plan options to find coverage that fits your budget and offers the best value.

Keep in mind that Medicare Advantage plan costs may change from year to year, so it’s important to review your coverage annually to make sure it’s still meeting your needs.

• Plan Renewal:

Advantage enrollees can stay in the plan until they choose to disenroll or if the plan changes.

• Figures:

Over 11 million enrollees each year since 2010.

What is Medicare Part D?

Part D is Medicare-approved coverage for prescription drugs, which you can get through a stand-alone Part D plan or a Medicare Advantage plan. Drug list includes most generic drugs and commonly used brand name drugs.

To get Medicare prescription drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered. Here are the two ways to get drug coverage:

• Medicare Part D:

Adds drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.

• Medicare Advantage Plan (Part C):

You get all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical

Insurance) coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” You must have Part A and Part B to join a Medicare Advantage Plan.

How to Join a Drug Plan:

• Enroll in the Medicare Plan Finder or on the plan’s website.

• Complete a paper enrollment form.

• Call the plan.

• Call 1-800-MEDICARE (1-800-633-4227).

• When you join a Medicare drug plan, you’ll give your Medicare number and the date your Part A and/or Part B coverage started. This information is on your Medicare card.

What determines the cost of prescription drugs with Medicare Part D?

• The drugs you use.

• The plan you choose.

• Whether you go to a pharmacy in your plan’s network.

• Whether the drugs you use are on your plan’s formulary.

• Whether you get extra help paying your Medicare Part D costs.

Key Reminder:

If your Medicare Advantage Plan (Part C) includes prescription drug coverage and you join a Medicare Prescription Drug Plan (Part D), you’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare. If you decide not to join a Medicare Prescription Drug Plan when you’re first eligible, and you don’t have other creditable prescription drug coverage, or you don’t get Extra Help, you’ll likely pay a late enrollment penalty.

What are the benefits of prescription drug plans or Medicare Part D?

When you enroll in Medicare you don’t automatically get prescription drug coverage.

Original Medicare Parts A and B don’t include prescription drug coverage, that’s why almost every senior has a prescription drug plan (either Medicare Part D or a Medicare Advantage plan). Getting your medication at little to no cost is important for living a healthier life as you age. Each plan includes coverage for thousands of commonly used generic and brand name prescription drugs, but offer slightly different coverage and drug lists. Here are some of the benefits that a prescription drug plan has to offer:

• Great value and coverage for the most commonly used prescription drugs.

• Low annual deductibles.

• The drug list includes most generic drugs and commonly used brand name drugs.

• You pay no more than 58% of the total cost for generic drugs or 45% of the total cost for brand name drugs, for any drug tier during the coverage gap.

• Copays as low as $0

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