Medicare guide
Medicare Advantage: How It Works
Medicare Advantage is an alternative to Original Medicare offered by private insurers approved by Medicare. Plans cover everything Parts A and B cover, usually include drug coverage, cap your in-network costs, and often add extras, in exchange for networks and rules like prior authorization. More than half of eligible beneficiaries now choose it.
Blake Insurance Group is an independent agency serving clients by phone, email, and online in states where we are licensed; coverage depends on the insurer, the policy, and underwriting.
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How Medicare Advantage works
You keep paying your Part B premium, and the plan provides your Part A and B benefits, usually with Part D drug coverage. Plans set their own copays, deductibles, and networks within federal rules, and must cap in-network out-of-pocket costs. Many offer extra benefits such as dental, vision, hearing, or fitness programs. Plans often require prior authorization for some services.
Medicare Advantage plans must cap in-network out-of-pocket costs for Part A and B services. For 2026, KFF reports the federal limit is $9,250 in network and $13,900 combined for in- and out-of-network services in PPOs, and that the average plan’s in-network limit is about $5,421. Original Medicare has no out-of-pocket cap, which is one reason people pair it with Medigap.
Plan types
| Type | How it works |
|---|---|
| HMO | Generally in-network care only, except emergencies, urgent care, and out-of-area dialysis; referrals usually required |
| HMO-POS | Like an HMO, but some out-of-network services allowed at higher cost |
| PPO | Out-of-network care allowed at higher cost; no referrals needed |
| PFFS | See any Medicare-approved provider that accepts the plan’s terms |
| SNP | Limited to people with Medicaid, certain chronic conditions, or institutional care; includes drug coverage |
| MSA | High-deductible plan with a medical savings account; no network; separate drug plan needed |
Source: Medicare.gov. Medicare Advantage plans often require prior authorization for some services.
When you can join or switch
| Period | When | What you can do |
|---|---|---|
| Initial Enrollment Period | 7 months around your 65th birthday month | Sign up for Parts A and B, and join a plan |
| Annual Open Enrollment | October 15 – December 7 | Join, switch, or drop Medicare Advantage or drug plans; coverage starts January 1 |
| Medicare Advantage Open Enrollment | January 1 – March 31 | One change: switch MA plans or return to Original Medicare (and add a drug plan) |
| General Enrollment Period | January 1 – March 31 | Sign up for Parts A and B if you missed your IEP; penalties may apply |
| Special Enrollment Periods | After qualifying events | For example, moving or losing employer coverage |
| Medigap Open Enrollment | 6 months from the first month you have Part B and are 65+ | Buy any Medigap policy sold in your state without health questions |
Source: Medicare.gov, October 2026.
Star Ratings
CMS released 2027 Star Ratings on October 8, 2026. About 71% of Medicare Advantage drug-plan enrollees are in contracts rated four stars or higher, 15 contracts earned five stars, and the enrollment-weighted average rating is 3.99. Star Ratings are one input; check the plan’s network, drug list, and costs too.
Changes for 2027
KFF counts 35.2 million Medicare Advantage enrollees in 2026, about 55% of eligible beneficiaries. For 2027, KFF’s analysis of CMS data found the average beneficiary can choose from 28 Medicare Advantage plans with drug coverage, but several large insurers are leaving some counties: UnitedHealth is exiting 228 counties, Humana 62, and Centene, Wellcare’s parent, 359 while entering 15. If your plan is leaving, you have a Special Enrollment Period and may have Medigap guaranteed issue rights.
For 2027, CMS set the Part D national base beneficiary premium at $41.33, up from $38.99 in 2026, and said it will end the Part D premium stabilization demonstration for standalone drug plans after 2026. The 2027 final rule keeps the Inflation Reduction Act’s redesign in place: there is no coverage gap, and there is no cost sharing once you reach the annual out-of-pocket threshold.
Medicare Advantage vs. Original Medicare
| Feature | Medicare Advantage | Original Medicare + Medigap + Part D |
|---|---|---|
| Provider choice | Network, depending on plan type | Any provider that accepts Medicare |
| Out-of-pocket cap | Yes, in network | Medigap covers most cost sharing |
| Premiums | Part B plus any plan premium | Part B plus Medigap and Part D premiums |
| Extras | Often dental, vision, hearing | Generally not included |
| Prior authorization | Often required for some services | Rarely |
Summary only. The plan documents control coverage, limits, and exclusions.
Special Needs Plans
Special Needs Plans are Medicare Advantage plans for specific groups, and all must include Part D drug coverage. Medicare.gov describes three types: Dual Eligible SNPs (D-SNPs) for people who have both Medicare and Medicaid; Chronic Condition SNPs (C-SNPs) for people with specific severe or chronic conditions, sometimes limited to one condition or a group of related conditions; and Institutional SNPs (I-SNPs) for people who live in, or need the level of care of, an institution such as a nursing home. You must have Parts A and B and live in the plan’s service area.
KFF counts about 8.2 million SNP enrollees in 2026, 23% of Medicare Advantage enrollment: D-SNPs make up 78% of SNP enrollment, C-SNPs about 1.7 million people after 45% growth from 2025, and I-SNPs about 124,000.
Signing up on time
Medicare charges late penalties if you delay without other qualifying coverage. Medicare.gov says the Part B penalty is 10% for each full 12-month period you could have had Part B but didn’t, usually for as long as you have Part B. The Part D penalty is 1% of the national base beneficiary premium for each month without creditable drug coverage after a 63-day gap; the base premium is $38.99 in 2026 and $41.33 in 2027. You can generally delay Part B without penalty if you have group coverage from current employment, and sign up within eight months after that coverage or employment ends.
Checking a plan and insurer
- Networks. Confirm your doctors and hospitals are in the plan’s network.
- Drugs. Check each prescription on the plan’s formulary and its tier.
- Costs. Compare premiums, deductibles, copays, and the out-of-pocket maximum.
- Agent license. Confirm the agent is licensed in your state through your state insurance department.
- Star Ratings. Review the plan’s rating on Medicare.gov’s Plan Finder.
What an independent agency does
An independent insurance agency is licensed to sell policies from several insurance companies. Instead of quoting one company's products, an independent agent can compare options from the insurers the agency represents, explain the differences in coverage, and help you re-shop at renewal. The insurance company, not the agent, makes underwriting and claim decisions.
Blake Insurance Group is an independent agency. We work with clients by phone, email, and online in states where we are licensed, and we will tell you which insurers we can quote for your situation.
How we work
Blake Insurance Group serves clients by phone, email, and online in states where we are licensed. The insurers and plans we can offer depend on our appointments and your location; a company named on this page may not be available through us.
How to verify an insurer or agency
Before buying through any website or app, confirm who is selling you the policy and who will issue it:
- Find the licensed agency or insurer named in the site's footer, terms, or license page.
- Look up the agency or producer on your state insurance department's license search, or through the National Insurance Producer Registry (NIPR).
- Look up the insurer on your state insurance department's company search to confirm it is authorized in your state.
- Save the insurer's name and policy number once issued, since that is who handles claims.
A legitimate service will make this information easy to find. Be cautious if you cannot identify the licensed entity.
Sources
We checked the facts on this page against the sources below in October 2026. Plans, prices, and rules change, so confirm current terms before you buy.
- Medicare.gov: Compare Medicare Advantage plan types
- KFF: Medicare Advantage out-of-pocket limits
- KFF: Medicare Advantage enrollment update (2026)
- KFF: Medicare Advantage plan availability for 2027 (Oct. 2026)
- Medicare.gov: Joining a health or drug plan
- Medicare.gov: When does Medicare coverage start?
- CMS: 2027 Medicare Advantage and Part D Star Ratings (Oct. 2026)
- CMS: Part D 2027 national average monthly bid information (July 2026)
- CMS: Contract Year 2027 Medicare Advantage and Part D final rule (Apr. 2026)
- Medicare.gov: Special Needs Plans
- Medicare.gov: Medigap guaranteed issue rights
- Medicare.gov: Avoid late enrollment penalties
What to have ready for a Medicare review
These details help an agent quote accurately.
- Medicare card. Your Medicare number and Part A and B start dates.
- Doctors. Names of doctors and hospitals you want to keep.
- Prescriptions. Drug names, doses, and pharmacies.
- Current coverage. Any plan, employer, or Medicaid coverage you have.
- ZIP code. Plans differ by county.
Medicare Advantage FAQs
What is Medicare Advantage?
A private plan approved by Medicare that provides Part A and B benefits, usually with drug coverage.
Is Medicare Advantage free?
Some plans have $0 premiums, but you still pay your Part B premium and plan copays.
Can I switch back to Original Medicare?
Yes, during Open Enrollment or the Medicare Advantage Open Enrollment Period. Medigap may require health questions outside guaranteed issue situations.
What happens if my plan leaves my county?
You get a Special Enrollment Period and may have Medigap guaranteed issue rights.
Related guides
Partner quote options
Sponsored
Blake Insurance Group works with the partners below. Each link opens the partner's own website, where its terms, eligibility rules, and privacy policy apply. Blake Insurance Group may be compensated if you buy through these links.
- Wellcare Medicare plans (online enrollment): View Wellcare Medicare Advantage and prescription drug plans available in your ZIP code and enroll online with Blake Insurance Group as your agent.
Important information
Compensation. Links in the partner section of this page are sponsored, and Blake Insurance Group may be paid if you make a purchase. Sponsored placement does not affect the other information on this page.
Independent agency. Blake Insurance Group LLC is an independent insurance agency. Licensed insurance producer NPN 16117464. Licensed states: AZ, AL, TX, CA, NY, OH, FL, NC, VA, GA, OK, NM, IA, KS, MI, NE, SC, SD, WV, IL, NJ, PA, TN, and WA. Which insurance companies we can quote depends on our current appointments, the product, and your state. Mentioning a company on this page does not mean we represent it.
Medicare disclaimer. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE (TTY users 1-877-486-2048), or your local State Health Insurance Assistance Program (SHIP) to get information on all of your options.
Medicare figures. Costs, limits, and rules on this page were checked against CMS, Medicare.gov, and the other listed sources in October 2026. 2027 Part A and B amounts had not been announced. Confirm current figures at Medicare.gov.
Coverage terms. Descriptions are general. The policy contract controls what is covered.
Availability. Coverage, prices, and eligibility vary by company, state, and applicant, and are subject to underwriting. The issued policy controls.
Your next step
Request a quote, and a licensed agent will compare options available to us for your situation.
