Medicare Advantage plans cover everything Original Medicare (Part A and Part B) covers, plus most plans bundle in prescription drug coverage and extras like dental, vision, and hearing that Original Medicare leaves out. These plans are sold by private insurance companies but approved and regulated by Medicare, which means they must meet federal minimums for coverage. Where they differ from one another is in the additional benefits they offer, the networks they use, and what you pay out of pocket.
Hospital and Medical Coverage
Every Medicare Advantage plan is required by law to cover the same hospital and medical services as Original Medicare. That includes inpatient hospital stays, skilled nursing facility care, home health services, and hospice under Part A. It also includes doctor visits, outpatient surgery, lab tests, imaging, durable medical equipment, and preventive screenings under Part B. If Original Medicare covers it, your Advantage plan must cover it too.
The difference is in how much you pay. The plan, not Medicare, sets your premiums, deductibles, and copays for each service. Two plans in the same zip code can charge very different amounts for the same knee surgery or specialist visit. Plans reset these costs every January 1, so it’s worth reviewing your plan’s terms each fall during open enrollment.
Prescription Drug Coverage
Most Medicare Advantage plans include Part D prescription drug coverage built in, so you don’t need to enroll in a separate drug plan. HMO and PPO plans that include drug coverage are sometimes labeled MA-PD plans. A few plan types, like Medical Savings Account plans and some Private Fee-for-Service plans, don’t include drug coverage and allow you to join a standalone Part D plan instead. However, if you’re in an HMO or PPO that doesn’t include drug coverage, you cannot add a separate drug plan.
Each plan maintains its own formulary, which is the list of drugs it covers and how much you pay for each one. Plans can make changes to the formulary during the year in certain situations, which could raise or lower what you pay for a specific medication. Your overall drug costs, though, can only change once a year on January 1. If you take expensive or specialized medications, checking whether they’re on a plan’s formulary before enrolling is one of the most important steps you can take.
Dental, Vision, and Hearing Benefits
This is one of the biggest reasons people choose Medicare Advantage over Original Medicare. Original Medicare does not cover routine dental care, eyeglasses, or hearing aids. Many Advantage plans do, though the scope varies widely from plan to plan.
Some plans cover only preventive dental services like cleanings and X-rays, while others include more comprehensive work like crowns, dentures, or extractions. Vision benefits typically cover routine eye exams and may include an allowance toward glasses or contacts. Hearing benefits can include annual hearing exams and, in some plans, partial coverage for hearing aids. The specifics, including dollar limits and copays, differ by plan, so these details are worth comparing side by side if they matter to you.
Wellness, Fitness, and Other Extras
Many Medicare Advantage plans go beyond medical care and offer benefits designed to keep you healthy and independent. Common extras include:
- Gym memberships: Programs like SilverSneakers give members access to participating fitness centers and group exercise classes at no additional cost. Eligibility depends on your specific plan.
- Over-the-counter allowances: Some plans provide a quarterly or monthly credit you can use to buy health-related items like vitamins, pain relievers, or first-aid supplies.
- Transportation: Rides to medical appointments, pharmacies, or other health-related destinations are offered by some plans, often with a set number of trips per year.
- Meal delivery: After a hospital stay or surgery, certain plans cover temporary home-delivered meals.
- Telehealth: Advantage plans often offer broader telehealth access than Original Medicare, letting you see providers virtually from home regardless of where you live. Medicare currently covers telehealth services through December 31, 2027, but many Advantage plans go further with additional virtual care options.
Not every plan offers all of these, and the value of each benefit varies. A generous-sounding OTC allowance might only be $25 per quarter, or a dental benefit might cap at $1,000 per year. Reading the plan’s Evidence of Coverage document reveals the actual limits.
HMO vs. PPO: How Network Type Affects Coverage
The type of Medicare Advantage plan you choose determines how freely you can see providers. HMO plans generally require you to use in-network doctors and hospitals for all non-emergency care. If you go out of network for a routine visit, you’ll typically pay 100% of the cost yourself. Emergencies and out-of-area urgent care are exceptions, as HMOs must cover those regardless of network.
PPO plans give you more flexibility. You can see both in-network and out-of-network providers, but you’ll pay significantly less when you stay in network. Choosing an out-of-network doctor for a procedure or ongoing care means higher copays and coinsurance. For people who travel frequently, split time between two states, or want to keep a specialist who isn’t in any local network, a PPO plan’s flexibility can be worth the trade-off of slightly higher premiums.
Special Needs Plans
Special Needs Plans, or SNPs, are a category of Medicare Advantage designed for people with specific health situations. There are three types: plans for people who qualify for both Medicare and Medicaid (called D-SNPs), plans for people living in certain institutional settings like nursing facilities, and plans for people with severe chronic conditions like cancer, heart failure, or diabetes (called C-SNPs).
SNPs cover everything a standard Medicare Advantage plan covers but tailor their benefits, provider networks, and drug formularies to the group they serve. A plan for people with congestive heart failure, for example, might cover extra days in the hospital. D-SNPs help coordinate benefits between Medicare and Medicaid, which can simplify what is otherwise a confusing overlap of two programs. All SNPs are required to include Part D drug coverage and provide care coordination services.
Out-of-Pocket Limits
One financial protection Medicare Advantage offers that Original Medicare does not is a yearly cap on out-of-pocket spending. Original Medicare has no ceiling on what you could owe in a given year for covered services. Every Medicare Advantage plan must set a maximum out-of-pocket limit, and once you hit it, the plan pays 100% of covered services for the rest of the year.
The cap applies to in-network services in all plans. PPO plans set a separate, higher cap for combined in-network and out-of-network spending. These limits vary by plan, and lower caps generally come with higher monthly premiums. When comparing plans, the out-of-pocket maximum is one of the most meaningful numbers to look at, especially if you anticipate a surgery, ongoing treatment, or any year with heavy medical use.
Prior Authorization Requirements
Medicare Advantage plans can require prior authorization for certain services, meaning the plan must approve a procedure, test, or medication before you receive it. This is one of the key differences from Original Medicare, which rarely uses prior authorization. Plans use these requirements to manage costs, but they can delay care if an approval takes time or gets denied.
Starting in 2026, Medicare Advantage plans must publicly list every item and service that requires prior authorization, along with data on how often they approve and deny requests and how long decisions take. This transparency is new and will make it easier to compare how restrictive different plans are before you enroll. Each plan has an appeals process if a prior authorization request is denied, and urgent requests are handled on faster timelines than routine ones.