Key Takeaways

• Medicare Part C (Medicare Advantage) plans may seem convenient but can involve tradeoffs, including network restrictions, prior authorizations, and cost-sharing details that differ from Original Medicare.

• Before enrolling in a Part C plan, you should ask targeted questions about coverage limits, provider access, referrals, travel coverage, and annual out-of-pocket costs.

Understand What Part C Actually Covers

Medicare Part C, also known as Medicare Advantage, combines the benefits of Original Medicare Parts A and B. Most plans also include additional benefits like prescription drug coverage, vision, hearing, or dental services. However, these benefits are managed by private companies approved by Medicare and operate under their own rules, networks, and restrictions.

If you are considering a Medicare Advantage plan, it is crucial to ask questions that go beyond just “What does it cover?” Instead, explore how the coverage works, what limitations exist, and how costs are structured.

1. Are My Doctors and Hospitals in the Plan’s Network?

Medicare Advantage plans generally rely on provider networks. This means your access to care depends heavily on whether your preferred doctors and hospitals are considered in-network.

• Check provider directories. Ensure all your primary care providers, specialists, and hospitals are part of the plan.

• Ask about network stability. Providers can leave the network during the year, which may affect your continuity of care.

• Understand out-of-network rules. Some plans offer limited out-of-network coverage but at a much higher cost, or none at all.

2. What Happens If I Travel or Move Temporarily?

If you plan to travel frequently or live in multiple states throughout the year, network limitations can impact your access to healthcare.

• Ask about travel coverage. Does the plan cover routine care when you’re out of state?

• Learn about emergency care. Emergency and urgent care are typically covered anywhere in the U.S., but routine services often are not.

• Snowbirds beware. If you split time between two locations, make sure the plan has networks in both areas.

3. Do I Need Referrals for Specialists?

Some Medicare Advantage plans require referrals from your primary care physician to see a specialist.

• Ask whether referrals are required. Health Maintenance Organization (HMO) plans often do, while Preferred Provider Organization (PPO) plans may not.

• Evaluate how this affects access. Requiring referrals could delay treatment or add extra steps to your care journey.

4. Are There Prior Authorization Requirements?

Prior authorization means the plan must approve certain services, treatments, or medications before you receive them.

• Ask which services require prior approval. These may include diagnostic imaging, surgeries, or post-acute care.

• Understand the approval timeline. Delays in authorization can affect how quickly you can begin treatment.

• Review appeals processes. Know how to challenge a denial if prior authorization is refused.

5. What Are the Plan’s Out-of-Pocket Costs?

Medicare Advantage plans have an annual out-of-pocket maximum, unlike Original Medicare. But that doesn’t always mean fewer expenses.

• Confirm the in-network maximum. In 2025, the maximum is set at $9,350 for in-network care, but many plans have lower limits.

• Ask about combined out-of-network limits. For PPOs, the combined in- and out-of-network maximum can be as high as $14,000.

• Check copays and coinsurance. Costs for office visits, urgent care, or hospital stays can add up quickly.

• Factor in prescription drug costs. Most Part C plans include drug coverage, but with varying deductibles and tiers.

6. What Prescription Drugs Are Covered, and at What Cost?

Prescription drug coverage (Part D) is often bundled into Medicare Advantage plans, but each plan uses its own formulary.

• Ask for the formulary list. Make sure your current prescriptions are covered.

• Understand tier structures. Drugs are grouped into tiers with different cost levels.

• Check for step therapy. Some plans require you to try lower-cost drugs before approving more expensive options.

• Review the annual Part D deductible. In 2025, the deductible can be up to $590.

7. What Happens If My Health Changes Significantly?

While Part C plans offer extra benefits, they also rely heavily on managed care, which can become burdensome if your health needs increase.

• Ask about long-term care options. These are not typically covered, but some plans offer limited home health services.

• Understand care management policies. Will you be reassigned to a different provider if your health becomes complex?

• Inquire about plan stability. Sudden plan changes could affect your treatment continuity.

8. Can I Afford the Plan During a High-Usage Year?

When evaluating costs, it is easy to focus on premiums, but you should also consider the worst-case scenario.

• Estimate high-usage costs. What would your costs be in a year with multiple hospitalizations, therapies, or prescriptions?

• Review copays for major services. Outpatient surgery, specialist visits, and inpatient stays often carry high cost-sharing.

• Ask about catastrophic protection. Even though a yearly out-of-pocket limit exists, it may still stretch your budget.

9. How Often Do Plans Change Benefits or Networks?

Each year, Medicare Advantage plans may change their coverage, provider networks, and cost-sharing amounts.

• Review the Annual Notice of Change (ANOC). It details any plan modifications for the upcoming year.

• Ask how changes are communicated. Will you receive notice in time to make new decisions during Open Enrollment?

• Compare plan quality ratings. Star ratings help gauge performance, but don’t reveal every nuance.

10. What Are the Plan’s Supplemental Benefits—and Are They Useful to You?

Extra benefits are a common selling point for Medicare Advantage plans. But you should evaluate them carefully.

• Ask about benefit availability. Does the plan offer dental, hearing, vision, or fitness programs?

• Determine usage limitations. Are there dollar limits, frequency caps, or network-only requirements?

• Check if benefits are bundled. Some extras may only be available as part of a package.

• Review how claims are processed. Benefits that require upfront payment and later reimbursement may not be as convenient.

11. Can I Switch Plans If This One Doesn’t Work Out?

Choosing a Part C plan isn’t necessarily a permanent decision, but switching requires awareness of timelines.

• Know the Annual Enrollment Period. From October 15 to December 7 each year, you can switch plans for the following year.

• Understand the Medicare Advantage Open Enrollment Period. From January 1 to March 31, you can change Advantage plans or return to Original Medicare.

• Explore Special Enrollment Periods (SEPs). You may qualify due to moving, losing coverage, or other life events.

12. Is This Plan Truly a Better Fit Than Original Medicare Plus a Medigap Policy?

Many people consider Medicare Advantage because of extra benefits and lower upfront costs. However, the flexibility and predictability of Original Medicare plus a Medigap plan may better serve your needs.

• Compare total expected costs. Include premiums, deductibles, and copays.

• Evaluate provider access. Medigap policies usually allow you to see any provider who accepts Medicare.

• Consider future medical needs. Changing from Medicare Advantage to Medigap after the first year may require medical underwriting in most states.

Use These Questions to Guide a Smarter Medicare Decision

Medicare Advantage can offer meaningful benefits if it aligns with your healthcare needs, budget, and lifestyle. But it isn’t a one-size-fits-all solution. Asking the right questions before you enroll can prevent future surprises and costly missteps. The key is to think not just about your current situation but also about how your needs might evolve in the years ahead.

If you’re unsure about how a Medicare Part C plan would fit into your long-term healthcare strategy, reach out to a licensed agent listed on this website for personalized support.