Medicare Advantage: The Complete Guide to Colorado

Medicare Advantage—often referred to as Medicare Part C—is an alternative way to receive your federal Medicare benefits. Instead of the government paying your doctors directly for the services you use, the government pays a set monthly fee to a private health insurance company. That private company then takes on the responsibility of managing your healthcare, paying your medical claims, and providing your benefits.

If you are approaching age 65, or if you are already enrolled in Medicare and looking to re-evaluate your coverage, deciding between Original Medicare and Medicare Advantage is the single largest structural choice you will make regarding your healthcare. This guide provides a comprehensive overview of how Medicare Advantage functions, how to evaluate the 103 plans available across Colorado, the specific carriers operating in the state, and the exact rules for enrollment.

What is Medicare Advantage (Part C)?

To understand Medicare Advantage, you must first understand the baseline it replaces: Original Medicare.

Original Medicare is managed directly by the federal government and is split into two primary parts:

• Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home healthcare.
• Part B (Medical Insurance): Covers outpatient care, doctor visits, preventive services, and medical supplies.

While Original Medicare offers the ultimate freedom to see any doctor in the United States who accepts Medicare, it has a significant financial flaw: it covers about 80% of your Part B medical costs, leaving you responsible for the remaining 20%. Crucially, Original Medicare has no maximum out-of-pocket cap. If you face a severe illness that costs hundreds of thousands of dollars, your 20% responsibility is uncapped and infinite. Furthermore, Original Medicare does not cover routine prescription drugs, dental, vision, or hearing care.

Medicare Advantage (Part C) was created to offer an alternative path. When you enroll in a Medicare Advantage plan, you do not lose your Medicare benefits; rather, you choose to receive them through a private insurance carrier approved by the Centers for Medicare & Medicaid Services (CMS).

By law, every Medicare Advantage plan must cover all of the medically necessary services that Original Medicare covers. However, they structure the costs differently. Instead of paying 20% of every bill, you will typically pay flat copayments (e.g., $10 to see a primary care doctor, $45 to see a specialist, or $250 for an ambulance ride). Most importantly, Medicare Advantage plans introduce a mandatory Maximum Out-of-Pocket (MOOP) limit, stopping your financial hemorrhage in the event of a catastrophic health year.

Because private carriers are competing for your enrollment, they frequently bundle additional benefits into their plans to make them more attractive, such as prescription drug coverage, dental cleanings, and gym memberships.

The Medicare Advantage Landscape in Colorado

Colorado’s Medicare Advantage market is robust and highly competitive. For the current plan year, there are 103 distinct Medicare Advantage plans approved for sale in the state. However, healthcare is inherently local. You do not shop for plans at the state level; you shop at the county level. The plans available to a resident of Denver County will differ from the plans available to a resident of Ouray or Yuma County.

Eleven health insurance carriers currently offer Medicare Advantage plans in Colorado. When evaluating plans, you will see offerings from:

• Aetna Medicare
• Anthem Blue Cross and Blue Shield
• Clear Spring Health
• Devoted Health
• Elevate Medicare Advantage
• HealthSpring
• Humana
• Kaiser Permanente
• Perennial Advantage
• Select Health
• UnitedHealthcare

These carriers offer a variety of plan structures to fit different budget tolerances, prescription needs, and provider preferences.

Decoding a Plan Name

When shopping for coverage, plan names carry vital information about the product. Consider these real examples of UnitedHealthcare plans available in Colorado:

• AARP Medicare Advantage Essentials from UHC CO-2 (HMO-POS)
• AARP Medicare Advantage from UHC CO-0013 (PPO)

A plan name typically tells you the carrier (UHC / UnitedHealthcare), the branding partnership (AARP), the internal tier or pricing structure (Essentials), the regional identifier (CO-2), and the network type (HMO-POS or PPO). Understanding the network type at the end of the plan name is the most critical step in determining how a plan will dictate your access to doctors.

How Medicare Advantage Provider Networks Work

With Original Medicare, your network is the entire country. With Medicare Advantage, your network is managed by the insurance company. If you do not follow your plan’s network rules, you could be held fully responsible for the cost of your medical care.

There are several types of Medicare Advantage networks available in Colorado. The vast majority of plans fall into one of three categories: HMO, PPO, or HMO-POS.

Health Maintenance Organization (HMO)

An HMO plan requires you to receive all of your routine and non-emergency care from doctors, hospitals, and facilities that are contracted with the insurance company.

• Primary Care Physician (PCP): You must usually select a primary care doctor to manage your care.
• Referrals: If you need to see a specialist (like a cardiologist or a dermatologist), your PCP must typically issue a referral before the plan will pay for the visit.
• Out-of-Network Care: Except for genuine, life-threatening emergencies or urgent care, HMOs do not pay for out-of-network care. If you see a doctor outside the network without authorization, you will pay 100% of the bill.
• Cost Profile: Because the insurance company tightly controls where you get care, HMOs generally feature the lowest premiums and the lowest out-of-pocket copayments.

Preferred Provider Organization (PPO)

A PPO plan offers more flexibility than an HMO, but at a slightly higher cost.

• Primary Care Physician (PCP): You are usually not required to formally select a PCP, though it is encouraged.
• Referrals: You do not need referrals to see a specialist. You can book an appointment directly.
• Out-of-Network Care: PPOs allow you to see any doctor or use any hospital outside the network, provided the provider is willing to accept your plan’s payment terms and treats Medicare patients. However, you will pay a higher cost-sharing amount (often a percentage-based coinsurance rather than a flat copay) for out-of-network care.
• Cost Profile: PPOs frequently have slightly higher out-of-pocket costs to offset the freedom they provide.

HMO Point-of-Service (HMO-POS)

An HMO-POS is a hybrid between an HMO and a PPO. Several of the UnitedHealthcare plans available in Colorado (such as the AARP Medicare Advantage Essentials from UHC CO-2 (HMO-POS)) utilize this structure.

• Like a standard HMO, an HMO-POS uses a strict network of providers and usually requires a designated PCP.
• However, the “Point-of-Service” designation means the plan will allow you to go out-of-network for certain specific services under certain conditions, usually with a higher copayment or coinsurance. It is critical to read the plan’s Evidence of Coverage to understand exactly which services are allowed out-of-network, as it is rarely a blanket allowance for all medical care.

Emergency care is treated exactly the same across all network types. Under federal law, if you experience a genuine medical emergency anywhere in the United States, your Medicare Advantage plan must cover your emergency room visit at the in-network cost-sharing rate, regardless of whether the hospital is in your plan’s network.

Understanding the Costs of Medicare Advantage

Evaluating a Medicare Advantage plan requires looking past the monthly premium and understanding how the plan splits costs with you when you actually use medical services.

1. The Part B Premium (The Unavoidable Cost)

The most common misunderstanding regarding Medicare Advantage is the concept of a “$0 premium plan.” While many Medicare Advantage plans do charge $0 for their portion of the coverage, you must continue paying your standard Medicare Part B premium to the federal government.

Your Part B premium is deducted directly from your Social Security check (or billed to you directly if you have not yet claimed Social Security). Medicare Advantage plans do not erase this obligation; maintaining Part B is a legal prerequisite for holding a Part C plan.

2. The Plan Premium

In addition to the Part B premium, some Medicare Advantage plans charge their own monthly premium. This is common if the plan has a very robust network (like a broad PPO) or exceptionally generous dental and vision benefits. Many plans in Colorado charge $0, relying entirely on the government subsidy they receive for managing your care.

3. Deductibles

A deductible is the amount you must pay entirely out of your own pocket before the plan begins splitting costs with you. Medicare Advantage plans can have two distinct deductibles:

• Medical Deductible: Many plans set this at $0, meaning coverage for doctor visits starts immediately.
• Prescription Drug Deductible: Often applied only to higher-tier medications (Tier 3, 4, and 5). If your plan has a $200 drug deductible, you will pay the first $200 for those specific drugs before your standard pharmacy copays apply.

4. Copayments and Coinsurance

This is how you pay for day-to-day healthcare.

• A copayment is a flat, predictable dollar amount. For example, your plan might dictate a $10 copay for a primary care visit, a $45 copay for a specialist, and a $300 copay for each day of an inpatient hospital stay (usually capped at a certain number of days, like Days 1-5).
• A coinsurance is a percentage of the total bill. If a service requires a 20% coinsurance, and the bill is $1,000, you pay $200. Coinsurance is most common for expensive procedures, such as chemotherapy, durable medical equipment (like a CPAP machine), or out-of-network care on a PPO plan.

5. Maximum Out-of-Pocket (MOOP) Limit

The MOOP is the most important financial feature of a Medicare Advantage plan. This is the absolute maximum amount of money you will spend on approved, in-network, medical services during the calendar year.

If your plan has a $5,000 MOOP, and you require open-heart surgery, extended hospital stays, and daily specialist visits, you will continue paying your $45 copays and $300 hospital daily copays until your total spending hits $5,000. Once you reach that threshold, the insurance company steps in and pays 100% of your approved medical costs for the remainder of the year.

Note: Your monthly premiums and your prescription drug costs (Part D) do not count toward your medical MOOP. Part D has its own separate limit structure.

Included Coverage: What the “Extras” Actually Mean

Because Original Medicare covers only hospital and medical services, private carriers differentiate their Medicare Advantage plans by bundling in ancillary benefits. These “extras” are heavily marketed, but it is important to understand how they mechanically function.

Prescription Drug Coverage (Part D)

The overwhelming majority of Medicare Advantage plans are “MA-PD” plans, meaning Medicare Advantage + Prescription Drug coverage. By integrating Part D into the plan, you carry a single ID card and use a single carrier for doctors and pharmacies.

Every MA-PD plan has a Formulary, which is the official list of drugs the plan covers. Formularies are divided into tiers (Tier 1 is preferred generic, Tier 2 is standard generic, Tier 3 is preferred brand name, etc.). The higher the tier, the more you pay. You must verify that your specific daily medications are on a plan’s formulary before enrolling; assuming a drug is covered because it is common is a dangerous financial mistake.

Dental, Vision, and Hearing

Original Medicare does not cover routine eye exams, glasses, hearing aids, dental cleanings, or dentures. Most Medicare Advantage plans offer these benefits, but usually through strict allowances or networks:

• Dental: Often includes two free cleanings and x-rays a year. Comprehensive dental (crowns, root canals, extractions) may be capped at a specific dollar amount per year, such as a $1,500 maximum benefit.
• Vision: Typically covers one routine eye exam per year and provides a set monetary allowance (e.g., $200) toward the purchase of frames and lenses.
• Hearing: Covers an annual hearing exam and heavily discounted pricing for specific models of hearing aids.

Over-the-Counter (OTC) Allowances and Fitness

Many Colorado plans offer fitness benefits, most commonly a free membership to participating gyms via programs like SilverSneakers or Renew Active.

Additionally, plans often provide a quarterly Over-the-Counter (OTC) allowance. This is typically loaded onto a prepaid debit card sent to you in the mail, which can be used at pharmacies like Walgreens or CVS to purchase eligible health items: bandages, vitamins, pain relievers, cold medicine, and toothpaste. If the allowance is $50 per quarter, it usually does not roll over; if you do not spend it, you lose it.

The Rules of Enrollment: When Can You Join?

You cannot enroll in, drop, or change a Medicare Advantage plan whenever you want. You are restricted to specific enrollment windows governed by federal law. Missing these windows can result in being locked into a plan for an entire calendar year.

Initial Enrollment Period (IEP)

When you first become eligible for Medicare at age 65, you are granted a 7-month Initial Enrollment Period. This window begins three months before your 65th birth month, includes your birth month, and ends three months after your birth month. During this time, you can enroll in any Medicare Advantage plan available in your Colorado county.

Annual Election Period (AEP)

The most critical window of the year is the Annual Election Period, which runs from October 15th to December 7th every year.

During AEP, anyone on Medicare can make changes to their coverage. You can:

• Switch from Original Medicare into a Medicare Advantage plan.
• Switch from one Medicare Advantage plan to a different Medicare Advantage plan.
• Drop your Medicare Advantage plan and return to Original Medicare.

Any changes made during AEP take effect on January 1st of the following year.

Medicare Advantage Open Enrollment Period (MA OEP)

If you are already enrolled in a Medicare Advantage plan on January 1st, you are granted a secondary window called the Medicare Advantage Open Enrollment Period. This runs from January 1st to March 31st.

During this window, you are allowed one single opportunity to correct a mistake. You can switch to a different Medicare Advantage plan, or you can drop your plan entirely and return to Original Medicare (and pick up a standalone Part D plan). This window is only for people who already have a Part C plan; you cannot use this window to move from Original Medicare into a Medicare Advantage plan.

Special Enrollment Periods (SEP)

Life events can trigger a Special Enrollment Period, allowing you to change plans outside the standard windows. Common triggers include:

• Moving to a new address outside your current plan’s service area (e.g., moving from Denver County to another state, or even just moving to a different county in Colorado if your plan does not operate there).
• Losing credible employer health coverage.
• Qualifying for, or losing, Medicaid assistance or Extra Help for prescription drugs.
• Moving into, or out of, a skilled nursing facility or long-term care hospital.

The Alternative: Medicare Advantage vs. Medigap

When leaving Original Medicare, you essentially arrive at a fork in the road: you can choose Medicare Advantage, or you can choose Original Medicare paired with a Medicare Supplement (Medigap) policy. It is vital to understand the difference, as these two paths are structurally opposed.

A Medigap policy does not replace Original Medicare. Instead, it pays the 20% coinsurance that Original Medicare leaves behind.

• Cost predictability vs. Upfront cost: Medigap plans charge high monthly premiums (often $150 to $300 a month in Colorado, depending on your age and the plan type). However, in exchange for that high premium, your out-of-pocket costs at the hospital or doctor’s office are practically zero. Medicare Advantage flips this: low upfront premiums, but you pay copays as you use the healthcare system.
• Networks: Medigap plans have no network restrictions. You can see any doctor in the country who accepts Original Medicare. Medicare Advantage requires you to stay within the carrier’s local HMO or PPO network.
• Underwriting: If you join a Medicare Advantage plan during your IEP, and later decide you hate the network restrictions and want to buy a Medigap policy instead, the Medigap carrier is legally allowed to ask you medical questions. If you have developed a severe condition (like cancer or heart disease), the Medigap carrier can permanently deny you coverage. Therefore, choosing Medicare Advantage is often a long-term decision.

How to Choose a Medicare Advantage Plan in Colorado

With 103 options statewide and nearly a dozen carriers, picking the right plan requires a systematic approach. Do not choose a plan simply because a neighbor recommended it; their health needs and medications are different from yours. Follow these steps to evaluate your options:

1. Anchor Your Doctors The best benefits in the world are useless if you cannot see the physicians you trust. Make a list of your primary care doctor, any specialists you see regularly, and your preferred hospital system (e.g., UCHealth, Centura, HealthONE). Check the carrier’s directory to ensure they are in-network. If you travel frequently or spend half the year in another state, an HMO is likely a poor fit; prioritize a PPO with out-of-network flexibility.

2. Audit Your Prescriptions This is where the math truly matters. Gather all your medication bottles. Check the dosage and the frequency. Look at the specific formulary for each plan you are considering. A medication might be a $10 Tier 2 copay on a Humana plan, but a $47 Tier 3 copay on a UnitedHealthcare plan. Over twelve months, that single drug categorization can cost you hundreds of dollars in differences.

3. Evaluate the MOOP Tolerance Look at the Maximum Out-of-Pocket limit. Plans with $0 premiums frequently have higher MOOP limits (e.g., $6,000 to $8,000). Ask yourself: if I am diagnosed with a serious illness this year and hit my absolute maximum limit, do I have the savings to write that check?

4. Compare the Meaningful Extras Ignore the marketing noise. Evaluate the extras based on what you will genuinely use. If you wear hearing aids, prioritize a plan with a strong negotiated discount for devices. If you need extensive dental work, prioritize a plan with a high annual dental maximum, even if the plan charges a small $15 monthly premium to get it.

Frequently Asked Questions