Frequently Asked Questions
How do I choose a Medicare Advantage plan?
The most important steps: (1) check that your current doctors are in the plan's network, (2) verify all your medications are on the plan's formulary at acceptable copays, (3) compare total annual costs including premiums, deductibles, and typical copays for your health needs, (4) check the out-of-pocket maximum, and (5) verify your preferred hospitals are in-network. Use Medicare.gov Plan Finder to compare all plans in your zip code.
What is the best Medicare Advantage plan?
There is no single best plan — the best plan depends entirely on your specific doctors, medications, and health needs. A plan rated 5 stars that does not include your cardiologist or your cancer center is the wrong plan for you. Always start with your doctors and medications, then find plans that cover them.
Can I switch Medicare Advantage plans every year?
Yes — you can switch Medicare Advantage plans every year during Annual Enrollment Period (October 15–December 7). Changes take effect January 1. There is also a Medicare Advantage Open Enrollment Period (January 1–March 31) for one additional plan change. Review your plan every year because networks, formularies, and costs change annually.
What is a Medicare Advantage HMO vs PPO?
HMO plans require you to use in-network providers and generally need referrals to see specialists. They have lower premiums and cost-sharing but less flexibility. PPO plans allow out-of-network care at higher cost-sharing and do not require referrals. PPOs are better for people who travel, have complex conditions, or want specialist access without referrals.
What is a Medicare Advantage star rating?
CMS rates Medicare Advantage plans 1–5 stars based on quality measures including preventive care, chronic disease management, member experience, and customer service. A 5-star plan allows you to switch plans at any time during the year outside normal enrollment periods. Star ratings are available at Medicare.gov.
Choosing the wrong Medicare Advantage plan costs the average senior $1,200–$3,000 per year in avoidable expenses — through out-of-network charges, uncovered medications, or prior authorization denials. The right plan is not the one with the lowest premium or the highest star rating. It is the one that covers your specific doctors, your specific medications, and your specific health needs. Here is exactly how to find it.
Step 1 — List Your Non-Negotiables
Before comparing any plans, write down three things:
- Your doctors: Primary care doctor, all specialists you see regularly, your preferred hospital. These are non-negotiable — if a plan does not include them in-network, eliminate it regardless of other benefits.
- Your medications: Every prescription with exact dosage and quantity. A plan that does not cover your medications — or places them on high-cost tiers — can cost you thousands more than a plan with a higher premium.
- Your health patterns: How often you see doctors, whether you have chronic conditions requiring specialist care, whether you travel regularly, whether you might need surgery in the coming year.
Step 2 — Check Doctor and Hospital Networks
This is the step most people skip — and it is the most expensive mistake. Call your doctor's office and ask: "Do you accept [plan name]?" Do not rely solely on the plan's online directory, which can be out of date.
For HMO plans, out-of-network care (except emergencies) is typically not covered at all. For PPO plans, out-of-network care is covered but at significantly higher cost-sharing. If you have a preferred specialist or cancer center, verify network participation before enrolling.
Step 3 — Check the Drug Formulary
Go to each plan's website and use their formulary search tool. Enter every medication you take and check: is it covered? What tier? What is the copay at your preferred pharmacy? Does it require prior authorization or step therapy?
Alternatively, use Medicare.gov Plan Finder — enter your medications and it automatically shows your estimated annual drug costs for every plan in your area.
Step 4 — Calculate Total Annual Costs
Do not compare plans by premium alone. Calculate total expected annual cost:
Total Annual Cost Formula:
Monthly Premium × 12
+ Annual Deductible
+ Expected Copays (doctor visits, specialist visits, lab tests)
+ Expected Drug Costs
= Your True Annual Cost
Step 5 — Check Out-of-Pocket Maximum
Medicare Advantage plans must cap your out-of-pocket costs — in 2026, the maximum is $9,350 in-network. However, this maximum varies widely between plans. A plan with a $3,500 out-of-pocket maximum provides significantly better financial protection than one with a $9,000 maximum if you have a serious health event. The lower the out-of-pocket max, the better your catastrophic protection.
Step 6 — Review Extra Benefits — But Don't Let Them Drive Your Decision
Medicare Advantage plans often include extra benefits not covered by Original Medicare: dental, vision, hearing, gym membership, over-the-counter allowances, and food benefits. These can add value — but they should never override the fundamentals. A plan with a $500 dental benefit that does not include your cardiologist is still the wrong plan.
If your fundamental needs (doctors, medications, costs) are covered equally by two plans, then extra benefits become the tiebreaker.
Step 7 — Use Free Help
SHIP counselors (State Health Insurance Assistance Program) provide free, unbiased Medicare plan comparison — they earn no commission and have no financial stake in which plan you choose. Find your state's SHIP at shiphelp.org or call 1-800-MEDICARE. They can sit with you and compare plans using your specific doctor and medication list.
- Always start with your doctors and medications — eliminate plans that don't cover them first
- Call your doctor's office to verify participation — don't rely only on online directories
- Compare total annual cost, not just monthly premium
- Check the out-of-pocket maximum for catastrophic protection
- Review your plan every October — networks and formularies change every January
- Use SHIP for free, unbiased help comparing plans