Medicare Advantage Plans -- How they work

Medicare Advantage Plans (Part C)

Medicare Advantage Plans (Part C) are all-in-one alternatives to Original Medicare, combining hospital, medical, and often prescription drug coverage. Many Advantage plans offer $0 or low monthly premiums. However, Advantage plans can end up being much more expensive and much more limiting than Medicare supplement plans. it’s important to understand what they do and don’t cover, and how their co-pays and out-of-pocket costs work.

What’s Included?:                                                                                   Hospital coverage (Part A)                                                                Medical coverage (Part B)                                                       Prescription drug coverage (Part D)                                        Emergency and urgent care

Extra benefits with most Advantage plans:                                        Dental coverage: Typically covers only one x-ray and two cleanings per year, usually with co-pays. More expensive dental work like fillings, crowns, or extractions are usually not covered or involve significant out-of-pocket costs.

Vision coverage: Usually only includes a max $200 benefit over two years towards glasses or contacts — not ongoing eye care.

Hearing coverage: May offer discounts on hearing aids and exams, but expect copays from $500 to $1,500 per device and restrictions on brands or providers.

Many people assume Advantage plans fully cover these areas. They do not. These benefits are limited and typically come with associated out-of-pocket costs.

Costs -- Medicare Advantage costs include:

A. Medicare Part B Premium -- Always Required

$185 per month for most people in 2025

B. Advantage Plan Premium -- Some plans have $0 premiums. Other plans can charge $100+ depending on benefits and location.

C. Deductibles & Copays -- These vary widely by plan.

Annual medical deductible: $0-$500 depending on the plan

Doctor's Office Visits: $0-$30 per visit

Specialists: $20-$60 per visit                                                    Outpatient Surgery: $100–$350 or 20% coinsurance                        Lab Services: $0–$20                                                                   Diagnostic Imaging (MRI, CT): $100–$300                                              X-rays:$10–$40 per image or per visit                                         Preventive Services (shots, screenings): covered 100% by law    Durable Medical Equipment (DME): 20% coinsurance               Ambulance (Ground): $250–$400                                                 Emergency Room (ER): $90–$120 usually waived if admitted            

D. Maximum Out-of-Pocket Limit (MOOP) -- All Advantage plans have an annual limit on what you spend on medical services.            MOOP for 2025: $8,850 (in-network services only)                

2025 maximum: $8,850 (in-network services only)

Many plans offer lower MOOPs but with higher monthly premiums.

Once you reach this limit, the plan pays 100% of covered services.

E. Prescription Drug Coverage (Part D)

Most MA plans include Part D coverage for free, but drug costs vary:

Copay examples for drug coverage:

Tier 1 (generic): $0–$10

Tier 2–3 (preferred/non-preferred): $20–$100+

Tier 4–5 (specialty medications): Coinsurance -- 25%–33% of total cost)

Long-Term Care: Protecting Your Comfort, Dignity, and FamilyNone of us likes to imagine when we might need help with everyday activities—like dressing, bathing, or simply getting around the house. But the truth is, about 70% of people over age 65 will need some form of long-term care during their lives. This kind of care can last months or even years, and while it’s essential for maintaining dignity and quality of life, Medicare does not cover most long-term care costs. For many families, this comes as a painful surprise—right when they’re already dealing with the stress of illness or aging.

What Medicare Covers — and What It Doesn’t Medicare's coverage for ongoing, personal care is very limited. It will pay for short-term skilled nursing, certain types of rehabilitation, and brief stays in a skilled nursing facility—but only under specific conditions:

-- Coverage is short-term and tied to recovery after hospitalization—typically up to 100 days. -- It doesn’t cover ongoing help with daily tasks like cooking, bathing, or getting dressed.

-- It does not pay for extended stays in assisted living or nursing homes unless those stays are for skilled medical care.

In short, Medicare helps for a little while—but not for the kind of long-term support most older adults eventually need.

National Median Monthly Costs for 2025

Home health aide -- 44 hours per week: $5,000–$6,000/month

Assisted living facility: $4,500–$5,500/month

Private room in nursing home: $9,000–$11,000/month

How Long-Term Care Insurance Can Help

Long-term care insurance provides funds to pay for care at home, in assisted living, or in a nursing facility—on your terms. Here’s how it works:

Benefits begin once you can’t perform two Activities of Daily Living—such as bathing, eating, dressing—or if you have a cognitive condition.

Flexibility of Care – You can choose coverage that includes home health aides, adult day care, assisted living, and nursing homes.

Benefit Amount & Length – You decide the daily or monthly amount the policy pays and for how long -- 3 years, 5 years, or lifetime.

Elimination Period before you are eligible for benefits -- usually 30–90 days.

Premiums are based on your age, health, benefit levels, and whether you include inflation protection so your coverage grows over time.

Long-term care planning protects savings and relationships. Without a plan, loved ones often carry the physical, emotional, and financial burden of providing care. With a plan, you can preserve your independence and dignity, and your family’s peace of mind.