What Is Medicare Advantage?
Medicare Advantage (MA), also called Medicare Part C, is an alternative way to get your Medicare benefits. Instead of Original Medicare (Parts A and B), you get coverage through a private insurance company approved by Medicare.
Key Point
Medicare Advantage plans must cover everything Original Medicare covers. However, they can add rules about how you get that coverage. This includes prior authorization, network restrictions, and referral requirements.
How MA Plans Work
When you join an MA plan, you still have Medicare. But instead of the federal government handling your claims, a private insurance company manages your benefits. Most MA plans also include:
- Prescription drug coverage (Part D)
- Extra benefits like dental, vision, and hearing
- Out-of-pocket maximums to limit your annual costs
- Gym memberships or fitness programs
About 51% of Medicare beneficiaries now choose Medicare Advantage. These plans can offer lower premiums and extra perks. But they also come with rules that affect how you access joint pain treatments.
MA vs Original Medicare for Joint Treatments
For joint pain care, the differences between Original Medicare and Medicare Advantage matter. Here is what you need to know:
| Factor | Original Medicare | Medicare Advantage |
|---|---|---|
| Coverage rules | Federal standards | Plan-specific (within Medicare rules) |
| Prior authorization | Rarely required | Often required for injections |
| Provider choice | Any Medicare provider | Usually network restrictions |
| Your cost | 20% coinsurance | Copays or coinsurance (varies) |
| Out-of-pocket max | None | Yes (protects against high costs) |
| Referrals | Not needed | May be required (HMO plans) |
What This Means for Joint Injections
Original Medicare covers hyaluronic acid (HA) injections for knee osteoarthritis with few hurdles. You see any Medicare-enrolled provider. No prior approval is needed. You pay 20% coinsurance.
Medicare Advantage must cover these same injections. But your plan may require:
- Prior authorization before treatment
- Using an in-network provider
- A referral from your primary care doctor
- Documentation of past treatments
These extra steps do not mean your plan is worse. They just mean you need to plan ahead. Understanding your plan’s rules prevents surprise denials and bills.
For complete details on Original Medicare coverage, see our Medicare coverage guide.
How to Check Your Plan’s Coverage
Every MA plan is different. Before scheduling joint treatment, verify your specific coverage.
Step 1: Find Your Evidence of Coverage
Your plan’s Evidence of Coverage (EOC) is your contract. It lists exactly what is covered and what you pay. You can:
- Find it online in your plan’s member portal
- Call your plan and ask for a copy
- Review the version mailed to you each fall
Look for sections on “injections,” “viscosupplementation,” or “outpatient services.”
Step 2: Call Member Services
The phone number is on your insurance card. Ask these questions:
- “Does my plan cover viscosupplementation for knee osteoarthritis?”
- “Is prior authorization required? How do I get it?”
- “What is my copay or coinsurance for this treatment?”
- “Do I need a referral from my primary care doctor?”
- “Are there network restrictions I should know about?”
Write down the representative’s name, the date, and any reference numbers.
Step 3: Verify Your Provider Is In-Network
Use your plan’s online directory to search for orthopedic or pain management specialists. Call the provider’s office to confirm:
- “Do you accept [your plan name]?”
- “Are you in-network for my specific plan?”
- “Is the facility also in-network?”
Both the doctor and the location must be in-network for lowest costs.
Prior Authorization in MA Plans
Prior authorization (PA) is the biggest difference between Original Medicare and Medicare Advantage for joint injections.
What Is Prior Authorization?
PA is pre-approval from your insurance plan before you get treatment. Your doctor submits a request with your medical records. The plan reviews it and decides whether to approve.
Important Warning
If you get treatment without required prior authorization, your plan will likely deny the claim. You could owe the full cost. Always verify PA status before your appointment.
How the PA Process Works
- Your doctor submits a request with your diagnosis, imaging results, and treatment history
- The plan reviews (usually 3-7 days for routine requests)
- You get a decision - approval, denial, or request for more information
- If approved, you schedule your treatment within the authorization window (usually 30-90 days)
Tips for Smooth Prior Authorization
- Start early - Submit PA requests 1-2 weeks before your planned treatment
- Provide complete records - Include X-rays, notes about past treatments, and medical necessity documentation
- Follow up - Call to check on pending requests
- Get it in writing - Keep the authorization number and approval letter
Network Requirements: HMO vs PPO
Your MA plan type determines how much flexibility you have in choosing providers.
HMO (Health Maintenance Organization) Plans
Strictest Network Rules
- Must use in-network providers (except emergencies)
- Need referrals to see specialists
- Out-of-network care usually not covered
- Often lower premiums
Best for: People who want lower costs and don’t mind using specific providers.
PPO (Preferred Provider Organization) Plans
More Flexibility
- Can see out-of-network providers but pay more
- No referrals typically required
- Coverage when traveling
- Higher premiums than HMO
Best for: People who want more provider choice and will pay more for it.
What If Your Provider Is Out-of-Network?
- PPO plan: You can still see them, but expect higher copays or coinsurance
- HMO plan: Generally not covered unless it is an emergency
- Consider switching: During Open Enrollment, you can change to a plan that includes your provider
Cost Comparison
Understanding your costs helps you budget for treatment and compare options.
Typical Costs for HA Injections
| Coverage Type | What You Pay |
|---|---|
| Original Medicare | 20% coinsurance (about $60-$150) |
| MA with copay | Fixed amount ($30-$100 typical) |
| MA with coinsurance | Percentage of cost (varies by plan) |
The Out-of-Pocket Maximum Advantage
Unlike Original Medicare, all MA plans have a yearly limit on what you pay out of pocket:
- 2026 federal limit: About $9,100 for in-network services
- Many plans set lower limits: $3,000-$6,000 is common
- After you hit the max: Plan pays 100% of covered services
This protects you from very high costs if you need multiple treatments or develop other health issues.
Cost Protection
If you have ongoing joint issues or other health conditions, the MA out-of-pocket maximum can save you thousands compared to Original Medicare with no limit.
Extra Benefits That May Help
Many MA plans include benefits useful for joint pain:
- Gym memberships (SilverSneakers, Renew Active)
- OTC allowances ($25-$150 per month for pain relief products, braces)
- Transportation to medical appointments
- Telehealth for follow-up care
Switching Plans During Open Enrollment
If your current MA plan is not meeting your needs for joint pain care, you can change plans.
When You Can Switch
Key Enrollment Periods
- Annual Enrollment (Oct 15 - Dec 7): Switch MA plans or return to Original Medicare
- Open Enrollment (Jan 1 - Mar 31): Switch MA plans or drop to Original Medicare
- Special Enrollment: If you move, lose coverage, or qualify for other reasons
Reasons to Consider Switching
- Your preferred provider is not in-network
- Prior authorization requirements are too burdensome
- You want lower costs for treatments you need often
- You are moving to a new area
- A better plan is available in your area
How to Compare Plans
- Use Medicare Plan Finder at Medicare.gov
- Check Star Ratings (quality scores from 1-5 stars)
- Look at total costs (premiums + expected out-of-pocket)
- Verify your providers and medications are covered
- Review prior authorization requirements for treatments you need
Getting Help
Navigating Medicare Advantage can be confusing. Free help is available.
State Health Insurance Assistance Program (SHIP)
SHIP counselors provide free, unbiased help with Medicare questions. They can:
- Explain your plan options
- Help you understand denials
- Assist with appeals
- Compare plans during enrollment
Find your local SHIP at shiphelp.org or call 1-877-839-2675.
Medicare.gov
The official Medicare website offers:
- Plan Finder to compare MA plans in your area
- Coverage information and eligibility tools
- Complaint forms if your plan violates rules
Visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).
Your State Insurance Department
If you believe your MA plan is not following the rules, your state insurance department can investigate. They handle complaints about:
- Improper denials
- Marketing violations
- Network adequacy issues
Key Takeaways
- MA plans must cover what Medicare covers but can add prior authorization and network rules
- Prior authorization is common for HA injections - always verify before treatment
- HMO plans require in-network providers; PPO plans offer more flexibility at higher cost
- Out-of-pocket maximums protect you from very high annual costs
- Extra benefits like gym memberships can support joint health
- You can switch plans during Annual Enrollment if your current plan is not working
- Free help is available through SHIP and 1-800-MEDICARE
Related Resources
- Medicare Coverage for Knee Injections - Original Medicare coverage details
- Medicare Gel Injections Coverage in 2026 - Latest coverage updates
- Prior Authorization Guide - Step-by-step PA process
- Understanding Out-of-Pocket Costs - Deductibles, coinsurance, copays explained
- Hyaluronic Acid Injections Guide
- How to Choose a Provider