Published May 16, 2026
This clear, balanced overview of Medicare Advantage pros and cons will help you determine if it suits your needs.
Medicare Part C, also known as a Medicare Advantage Plan, replaces Original Medicare and often includes extra benefits.
But first, it's important to understand all the parts of Original Medicare.
Original Medicare has two parts that cover your most crucial health expenses:
Together, these cover 80% of your healthcare costs.
You still pay the deductible and are responsible for the other 20%. However, that’s 20% of what Medicare approves for the billing, not 20% of what the doctor or hospital charges. Not many people realize that.
In addition to original Medicare, you can get an optional supplemental plan that pays the 20% portion that Medicare doesn’t cover, less the deductible. That is also known as Medigap, which is essential if you are concerned about paying your 20% share.
Independent insurance companies provide supplemental plans.1
There are several different supplemental plans to choose from, labeled as Plans A through N, each with varying benefits and premiums.
Besides a supplemental plan that takes care of the 20% portion that is not covered by Original Medicare, you also need to consider having prescription drug coverage, known as Part D.
You need to subscribe to this with an independent insurance company. Each one has different tiers with various copays for various drugs.2
Part D is optional, but it's important to know that there is a penalty if you don’t have Medicare-approved Part D coverage after your 65th birthday.
The penalty will be added to your premium when you eventually do apply for it. Advantage plans avoid this trap because most plans include Medicare-approved Part D coverage.
The penalty is an accumulative amount of 1% per month. That means if you skip two years (24 months) and then sign up for a pharmaceutical plan, you’ll pay a penalty of 24% on top of the regular Part D premium.
Technically, that percentage is figured on the average nationwide Part D premium, not on the premium of the plan you choose.
In my opinion, it’s inaccurate to call this Part C. It always confuses people because it’s not really a part of Medicare. It’s a plan, an Advantage Plan, completely replacing Original Medicare.
Once you understand what I will cover here, you’ll be able to determine if it’s a better choice than Original Medicare for you.
There are two types of Advantage plans, Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).
PPOs offer much more choice in choosing health care. Most importantly, they don’t require a referral to see a specialist. That allows the specialist to make their own decision as to what to treat, as long as it’s covered.
They both cover the same medical services as Original Medicare parts A and B. In addition, they include additional benefits, which I’ll discuss below.
A Medicare Advantage plan takes over the entire record-keeping. You still need to pay for Medicare Part B or have that deducted from your Social Security payments. Most plans include an approved Part D creditable drug coverage.
The premium can also be deducted from Social Security if you prefer. These premiums are usually much lower because Medicare reimburses those private insurance companies for taking care of everything. Some plans even have a zero premium!
Advantage plans in every town or city offer different benefits. For example, the plan I have pays $200 a year towards eyeglasses or contact lenses and $50 a month for a gym membership. However, you need to review the plans available where you live.
Your Maximum Out-of-Pocket Responsibility
There is a limit to how much you would have to pay with accumulated co-pays per year. As long as you go to in-network providers, you no longer need to pay the co-pays once you reach that annual limit.
However, that limit is high, usually around $7,000. So, if you are in poor health and often need to see doctors, your co-pays can add up. Nevertheless, it’s good to know there is a limit to your out-of-pocket expenses.
How the Deductible Works With an Advantage Plan
Original Medicare doesn’t pay until the deductible is used up, but some Advantage plans pay the standard Medicare deductible for you.
Prior Authorization and Referral Requirements
Some procedures require prior authorization from your doctor. And in some cases, you need a referral from your primary doctor to see a specialist. However, there are exceptions, so check with the plan you are investigating.
You Still Need Medicare Parts A and B
With an Advantage Plan, you still need to pay the Medicare Part B (Medical Coverage) premium. That can be deducted from your Social Security.
If you’re over 65 and had health coverage through your employer or spouse’s employer, you still need to sign up for Medicare Parts A and B, even if you select an Advantage Plan.
The Benefits of Part C Advantage Plans
Every plan is different, and you need to compare what each insurance company includes with their Advantage Plan, but here is a review of the common benefits.
Advantage Plan Reimbursements
Many Medicare Advantage plans provide reimbursement for certain things not usually covered by Original Medicare. Here are things to look for, based on what you prefer having:
Prescription Drug Benefits Are Usually Included
Most Advantage plans include approved Part D coverage. That means you avoid the penalty for not having prescription drug coverage.
Prescription benefits are in a tiered structure. Many generic drugs are in tier 1, which have a low or zero co-pay. But other drugs fall into higher co-pay tiers.
If you are taking various medications, check with each plan to see how well you are covered. Each plan has different co-pays for specific drugs in various tiers.
In addition, some plans offer drugs through the mail with a zero co-pay.
You do need to watch out for charges if you order drugs from out-of-network providers.
Medicare Part-D Coverage Gap
If you use many drugs, you may fall within the Part-D Coverage Gap (also known as the Donut Hole).
So, you'll need to compare this among the advantage plans because each handles gap coverage differently.
Hospital Benefits
All advantage plans have their own structure for hospital costs, and it may be different for inpatient and outpatient.
Some plans have reasonable daily co-pays for the first week. Then you are fully covered and pay nothing for up to three months. That’s great for those who are generally healthy.
If you expect to need extended hospital stays, you might do better with Original Medicare with a supplemental plan added on, rather than an Advantage plan.
Preventive Care
If you use any of the following preventive services, confirm if your plan covers them. Most advantage plans have a zero co-pay for these services.
Dental Services
Original Medicare does not pay for dental work.
However, some Advantage plans pay for dental x-rays, an oral exam, and two cleanings every year. Check with the plans in your area.
Co-Pays for Doctor Visits
Every plan is different, but most Advantage Plans save you money with low co-pays:
Benefits in Common With Original Medicare
All benefits common to Medicare are included with Advantage plans. Below is a summary of these benefits.
Under an Advantage plan, the co-pays and limits might be better than with Original Medicare coverage. You need to compare that with the plans available in your area.
Vision Services
Routine eye exams and follow-up visits to diagnose and treat eye diseases and conditions are standard.
In addition, some plans include coverage for contact lenses or eyeglass prescriptions. Some plans even reimburse part of the cost of filling these prescriptions.
Emergency Care
All advantage plans cover emergency care when you need to visit a hospital ER. There is usually a higher co-pay, such as around $80.
Hearing Services
Routine hearing exams and Medicare-covered exams to diagnose and treat hearing issues are included.
Usually, one visit per year, but evaluation and fitting for hearing aids might be covered just once every other year.
Additional Coverage Usually Provided by Advantage Plans
Only One All-Inclusive Membership Card Is Required
With an Advantage Plan, you only need one card that covers everything.
If you have Original Medicare, with Part D and a supplemental plan, you need to carry three membership cards for coverage.
I did that the first year I was on Medicare, before I switched to an Advantage Plan.
When you are covered by an Advantage plan, you don't need to show your original Medicare card. Put that away in a safe place.
You don’t need it unless you go back to original Medicare. You also don't need a separate card for prescription drugs. It's all under one plan.
Medicare Advantage plans offer many benefits, but also have limitations that may not be good for people in poor health. Let's review the negatives.
How to Choose Doctors With an Advantage Plan
Advantage plans may not be the right choice if you have major health issues. That's because you are limited to doctors who are on the plan.
Besides, some doctors don't accept some Advantage Plans because they tend to pay doctors less than Medicare and Supplemental insurance.
Therefore, you may not always be able to choose the best doctors for your particular condition.
With Original Medicare, you can go to any doctor who accepts Medicare. You’re covered when you travel, too.
Advantage plans, on the other hand, have a network of doctors, hospitals, and pharmacies in your area.
If you use providers who are not in the network, the plan may not pay for those services.
You need to verify that the doctors you go to are in the network. They all list the in-network doctors online, so it’s easy to research.
In addition, doctors are known to drop off the plan at any time if they are not satisfied with the payment structure. Unfortunately, that means you may have to change doctors.
Choosing Pharmacies With an Advantage Plan
Most standard pharmacies are included, but you should check that.
You must use pharmacies that are in the network to fill your prescriptions for covered Part D drugs.
Travel Coverage Limitations With an Advantage Plan
If you travel a lot, you’ll want to be sure you're covered for any doctor who accepts Medicare, no matter where you are.
In that case, an Advantage plan is not the right choice for you since you can only use in-network doctors.
Some Advantage plans cover emergency services when outside the United States. However, those that do may not necessarily offer other valuable benefits.
That is why it's important to compare plans in your area and choose based on your needs.
You can change to a different advantage plan only once a year—during the open enrollment period near the end of the year.
If you move, you would have to select a new plan that exists in your new location. A special enrollment period allows you to make a change when you move.
Benefits can be added or eliminated upon the annual renewal. You will know that ahead of time so that you can decide to switch to another Advantage plan or back to Original Medicare during the open enrollment period.
My prior advantage plan had discontinued reimbursing for over-the-counter essentials. So during the open enrollment period, I switched to an Advantage plan with another insurance company that still offered that benefit.
I chose my Advantage plan because it gives me everything I need, plus other benefits I decided to use, such as a gym membership and eyeglass reimbursement.
Choosing between original Medicare and a Part C Advantage Plan depends on your specific needs, health considerations, and the plans available in your area.
So, consider all the pros and cons I discussed above to determine if Part-C is an advantage for you.
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