Medicare Advantage questions, in plain English

Medicare Supplement Insurance (Medigap) is extra insurance you can buy from a private company to help pay your share of costs in Original Medicare, such as copayments, coinsurance, and deductibles. With Original Medicare, you can generally see any doctor or hospital that accepts Medicare, anywhere in the U.S. Medicare Advantage (Part C) is a Medicare-approved plan from a private company that is an alternative to Original Medicare. These plans include Part A and Part B, and usually Part D. You often must use doctors in the plan’s network, except in emergencies. You cannot have a Medigap policy and a Medicare Advantage plan at the same time.

Your Initial Enrollment Period for Part A and Part B generally lasts 7 months. It starts 3 months before you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. After you have Medicare, you can join a Medicare Advantage or Part D plan only at certain times, unless you qualify for a Special Enrollment Period. Missing a sign-up window can mean waiting and, for Part A (if you pay a premium) or Part B, a late enrollment penalty in some cases. Part D also has a late enrollment penalty if you go without creditable drug coverage.

You do not pay Prime Integrity Insurance a separate fee for a plan review. If you enroll in a plan, you still pay the plan’s premium and other costs set by the insurer and by Medicare. Insurance companies typically pay agencies when someone enrolls. Compensation does not change the premium the plan charges you.

Medigap policies sold after 2005 do not include prescription drug coverage. If you want drug coverage with Original Medicare, you can join a separate Medicare drug plan (Part D). Medigap generally helps with costs for services Original Medicare covers. Routine dental and vision care are usually not covered by Original Medicare or by standard Medigap plans. Separate dental or vision coverage, if available, is a different product.

Standardized Medigap policies are automatically renewed each year, even if you have health problems, as long as you pay your premiums. The insurance company can drop you if you stop paying premiums, if you were not truthful on the application, or if the company goes bankrupt or out of business.

If you enroll through a Prime Integrity Insurance agent, that agent can remain a contact for questions about the plan, claims, billing, and yearly reviews. You can also get official Medicare information anytime at Medicare.gov or 1-800-MEDICARE.

No. Medicare does not offer family or couple plans. Each person makes a separate choice. One of you can have Original Medicare with Medigap, and the other can have Medicare Advantage, if that is what fits. Compare each person’s doctors, drugs, and costs on their own.

Yes. VA health care and Medicare are separate. Many veterans enroll in Medicare, including Advantage, so they can see non-VA doctors. You generally should not use both VA and Medicare for the same visit. If you get most care at the VA, a lower-cost drug plan or a different setup might fit better than a full Advantage plan. Bring your VA information when you compare options.

Medicare will not call you uninvited and ask for your Medicare number, bank account, or to pay by gift card. Be careful with unsolicited calls, texts, and door-to-door pitches. You can hang up and call 1-800-MEDICARE, your plan using the number on your card, or Prime Integrity Insurance at (877) 273-0393. Never give your Medicare number to a stranger who contacted you first.

Yes. Extra Help can lower Part D drug costs if you qualify. Medicare Savings Programs, run by your state, may help pay the Part B premium and other costs. Some people qualify for both Medicare and Medicaid. Extra Help and Medicaid can also create Special Enrollment Periods to change drug or Advantage coverage. Start at Medicare.gov or call 1-800-MEDICARE, and ask your state Medicaid office. A licensed agent can help you look, but the programs themselves are run by Medicare and your state.

Yes. Medicare Advantage is another way to get your Medicare Part A and Part B coverage. You still have Medicare. The private plan delivers your benefits and must follow rules set by Medicare. You usually use a plan member ID card for routine care instead of your red, white, and blue Medicare card. Keep your Medicare card in a safe place. You must keep paying your Part B premium to stay in the plan.

An HMO usually requires you to use doctors and hospitals in the plan’s network, except in an emergency. You often need a primary care doctor and referrals. A PPO has a network too, but you can usually see out-of-network providers for a higher cost, and you often do not need a referral. Some plans are Special Needs Plans (SNPs) for people with certain conditions or who also have Medicaid. Read the plan’s rules. Names like HMO or PPO tell you how care is set up, not whether the plan is a good fit.

Original Medicare generally does not cover routine dental, glasses, or hearing aids. Many Medicare Advantage plans offer some extra benefits in those areas, but they are not guaranteed and they vary by plan, county, and year. A plan might cover a cleaning but not dentures, or a hearing exam but not the hearing aid you want. Always read that year’s plan documents. Extra benefits can change at the start of a new year.

Medicare Advantage plans have a yearly limit on what you pay out of pocket for covered Part A and Part B services. Once you reach that limit, the plan pays 100% of those covered services for the rest of the year. The limit amount varies by plan. It does not always include Part D drug costs. Original Medicare by itself has no yearly cap unless you have other coverage such as Medigap or Medicaid.

Yes. You must have Part A and Part B, and you must keep paying the Part B premium to stay in a Medicare Advantage plan. Some plans charge an extra premium on top of Part B. A few plans may help pay part of the Part B premium. That help is not guaranteed and can change each year. Social Security usually deducts Part B from your benefit check.

No. You cannot use a Medigap policy to pay Medicare Advantage copays. If you join Advantage, you should not keep paying for Medigap for that purpose. If you already have Medigap and are thinking about Advantage, ask what happens to the Medigap policy and whether you could get similar Medigap later. Those rights are limited.

A plan cannot drop you just because your health gets worse. It can end your coverage in certain other cases, such as if you move out of the plan’s service area, you stop paying the plan premium, you lose Part A or Part B, or Medicare ends its contract with the plan. If the plan is leaving your area, Medicare will send information about your options. Call the plan or 1-800-MEDICARE if you get a disenrollment notice you do not understand.

No. A $0 premium means you do not pay an extra monthly amount to the plan on top of your Part B premium. You still pay the Part B premium. You can also owe copays, coinsurance, or a deductible when you use care, plus the yearly out-of-pocket maximum if you have a lot of services. Always look at the full cost picture — doctor visits, hospital stays, drugs, and extras — not only the monthly premium.

Yes. You must have Medicare Part A and Part B, live in the plan’s service area, and be a U.S. citizen or lawfully present. You also have to keep paying the Part B premium. If you only have Part A, you generally cannot join an Advantage plan until you also have Part B.

A service area is the place where the plan is allowed to enroll people, usually a county or a group of counties. You must live in that area to join. Emergency and urgent care still work when you travel. Routine care is meant to be used where the plan has its network. If you move out of the service area, you generally have to change plans.

These extras are optional plan benefits, not standard Medicare. An over-the-counter (OTC) card is usually a set dollar amount each quarter for approved items. Gym or fitness benefits only work at participating locations. Transportation may mean a limited number of rides to plan-approved medical visits, often with advance booking. Amounts and rules change by plan and year. If you do not use an extra, you generally do not get the cash instead.

Original Medicare generally does not pay for hearing aids. Some Medicare Advantage plans include a hearing benefit, often with a copay, an allowed amount, or a specific vendor. It may cover a hearing test but only part of the hearing aid. Read that year’s benefit chart and ask what brands and how many aids are included. Do not assume a $0 premium plan includes the hearing aids you want.

Only if that doctor is in your plan’s network — or if your plan type allows out-of-network care and you are willing to pay more. Many HMO plans require you to use in-network doctors for non-emergency care. PPO plans often let you go out of network, usually at a higher cost. Before you enroll, check the plan’s provider directory and call the doctor’s office to confirm they still take the plan. Directories can be out of date.

A provider can leave a plan’s network at any time. If that happens, you generally need to choose another in-network doctor for non-emergency care so the plan pays its share. Medicare says plans should make a good-faith effort to give you at least 30 days’ notice when a provider leaves. Check with the office when you schedule a visit. If you enrolled based on wrong directory information, you may qualify for a Special Enrollment Period to switch plans. Ask your plan or 1-800-MEDICARE.

It depends on the plan. Many HMO Medicare Advantage plans require you to choose a primary care doctor and get a referral before you see a specialist. Many PPO plans do not require a referral. Check your Evidence of Coverage or call the plan before you make the appointment. If you skip a required referral, the plan may not pay.

Prior authorization means you or your doctor must get the plan’s approval before it will cover certain services, supplies, or drugs. Medicare Advantage plans often require this for things like some imaging, procedures, medical equipment, or brand-name drugs. If the plan does not approve the request, you may have to pay the full cost. You have the right to appeal. Ask your doctor’s office to help with the paperwork, and call the plan if you are unsure whether approval is needed.

Medicare Advantage plans must cover emergency and urgent care, even if you are outside the plan’s service area. Go to the nearest emergency room if you think it is an emergency. For a sudden illness while you are away, urgent care is also covered. Routine visits, like a yearly checkup, usually are not covered out of the area unless your plan says otherwise. If you spend winters in another state, ask whether the plan has a visitor or travel program before you rely on it.

Yes. Medicare Advantage plans must cover dialysis when you are outside the plan’s service area. Call your plan before you travel so they can help you find a facility that will bill the plan. Keep your member ID card with you. If you have trouble getting an appointment, call the plan again or 1-800-MEDICARE.

Each year your plan must tell you if premiums, copays, doctors, drugs, or extra benefits will change for the next year. That letter is called the Annual Notice of Change. Plans typically send it before September 30. Read it. Open Enrollment (October 15–December 7) is when you can switch if the new year no longer fits. Costs and networks can change even if you stay in the same plan name.

You have the right to appeal. Start with your plan. The denial letter should explain how and when to appeal. For a service you have not received yet, you or your doctor can ask the plan for a coverage decision, including a fast decision if waiting could harm your health. Keep copies of letters and ask the doctor’s office to send records. You can also call 1-800-MEDICARE. Do not ignore a denial letter — appeal deadlines are real.

Most Medicare Advantage plans include Part D drug coverage, but each plan has its own list of covered drugs (a formulary) and preferred pharmacies. A drug you take today might be covered, limited, or not on the list. Before you enroll, have someone check your prescriptions and pharmacy against that year’s plan materials. If a drug needs prior authorization, ask your doctor to request it. In 2026, once you have paid $2,100 out of pocket for covered Part D drugs, you pay $0 for those covered drugs for the rest of the year. You still pay your premium.

For a copay, prior authorization, doctor network, or ID card, call the member services number on your plan card. For official Medicare rules, enrollment periods, or if you cannot reach the plan, call 1-800-MEDICARE (1-800-633-4227). TTY: 711. If you enrolled through Prime Integrity Insurance, you can also call us at (877) 273-0393. We can help you understand a letter or check options. We cannot replace Medicare or your plan’s decisions.

If you have a Medicare Advantage plan, show the plan’s member ID card for routine care. Your red, white, and blue Medicare card is still yours. Keep it. You usually do not use it for everyday visits while you are in Advantage. Bring both if you are not sure. If you also have Medicaid or other coverage, bring those cards too.

If you elect hospice, Original Medicare covers your hospice care even if you are in a Medicare Advantage plan. You can stay enrolled in the Advantage plan. The plan may still cover extra benefits it offers, and some services not related to your hospice diagnosis. Ask the hospice team and your plan so billing is clear. This is a Medicare rule, not something a plan can opt out of.

Medicare can help pay for skilled nursing facility care when you need skilled nursing or rehab, not for long-term custodial care like help with bathing if that is all you need. Original Medicare generally requires a qualifying hospital inpatient stay first. Some Medicare Advantage plans waive that three-day hospital rule. Coverage, copays, and prior authorization still apply. Ask the hospital case manager and your plan before you transfer. Observation status in the hospital is not the same as being admitted as an inpatient.

Observation means you are an outpatient in the hospital, even if you stay overnight. That can change what you pay and whether Medicare will help with a skilled nursing stay afterward. Ask, “Am I an inpatient or on observation?” You should get a Medicare Outpatient Observation Notice if you are in observation 24 hours or more. Call the hospital billing office or your plan if the status is unclear.

Usually no. Original Medicare and most Medicare Advantage plans do not cover routine or emergency care outside the U.S. There are narrow exceptions. Some Medigap policies include limited foreign travel emergency coverage, which Advantage does not replace. If you spend part of the year abroad or take cruises, ask before you travel and consider whether Original Medicare plus Medigap fits better.

A copay is a set dollar amount you pay when you get a service, such as $20 for a doctor visit. Coinsurance is a percentage, such as 20% of the bill. A deductible is what you pay first, before the plan starts sharing cost, if the plan has one. Your plan’s Evidence of Coverage lists these amounts. The front-desk estimate is not always the final bill if labs or imaging are billed separately.

Call the member services number you used before, or look up the plan’s phone number on Medicare.gov or in your paperwork. Ask them to mail a new card. Many plans also show your member ID in an app or mailed welcome kit. While you wait, the doctor’s office can often bill with your name, date of birth, and member number if you have a bill or letter that shows it.

Medicare Advantage contracts are for a calendar year. Premiums, copays, extra benefits, drug lists, and networks can all change on January 1 even if you keep the same plan name. That is why the Annual Notice of Change matters each fall. Open Enrollment (October 15–December 7) is the main time to switch if next year’s plan no longer fits.

Part D and Medicare Advantage drug benefits use pharmacy networks. A preferred pharmacy often has a lower copay than a standard one. Mail-order may be cheaper for 90-day supplies. Using a pharmacy outside the network can mean you pay much more. Check the plan’s pharmacy finder for the year you are in, and ask whether your independent pharmacy is preferred or standard.

Durable medical equipment can be covered when it is medically necessary, but Medicare Advantage plans often require prior authorization and a contracted supplier. You may have a copay. Buy a walker from a drugstore on your own and the plan may not reimburse you. Ask your doctor to write the order and call the plan for an in-network supplier before you purchase or rent equipment.

Medicare Advantage plans must cover Medicare-covered preventive services, including the yearly “Wellness” visit and many vaccines, and they generally cannot charge you for those preventive services when you use in-network providers the right way. A “sick” visit on the same day, labs, or extra tests can still have a copay. Ask the office to code a true preventive visit if that is what you scheduled.

The main time is Open Enrollment, October 15 through December 7. Changes usually start January 1. If you are already in a Medicare Advantage plan, you also get a Medicare Advantage Open Enrollment Period from January 1 to March 31. During that winter window you can make one change: switch to another Advantage plan, or go back to Original Medicare (and join a separate drug plan). You generally cannot use that winter window to leave Original Medicare and join Advantage. You may also qualify for a Special Enrollment Period if you move or lose other coverage.

You can return to Original Medicare during Open Enrollment or a qualifying Special Enrollment Period, and during the January 1–March 31 Advantage Open Enrollment Period if you are already in an Advantage plan. Buying a Medigap policy is a separate step. You have stronger rights to buy Medigap in limited “trial” situations — for example, if you joined Advantage when you first got Medicare at 65 and leave within the first year. Outside those windows, a Medigap company may ask about your health and can decline you, depending on state rules. Ask before you drop a plan.

Medicare Advantage plans have a service area, usually a county or group of counties. If you move out of that area, you generally cannot keep the same plan, and you get a Special Enrollment Period to pick new coverage where you live. Tell Social Security and your plan your new address. If you split the year between two homes, ask whether one address is your official residence for the plan. Moving is one of the most common reasons people need help changing plans mid-year.

You generally wait until the next Open Enrollment (October 15–December 7) unless you qualify for a Special Enrollment Period. Common examples: you move out of your plan’s area, you lose other coverage, you qualify for Extra Help or Medicaid, or your plan is leaving. From January 1 to March 31, people already in Medicare Advantage can make one switch. If you are not sure you qualify, call 1-800-MEDICARE or us and describe what changed.