Medicare Advantage Enrollment Information

How Medicare Advantage Is Like Original Medicare

Medicare pays the insurance company that provides your Medicare Advantage plan a fixed amount every month. That helps keep your Advantage plan premiums low (and sometimes $0), but you will still pay Medicare Part B premiums.

Advantage plans must follow the rules established by Medicare. As an Advantage plan holder, you will retain all of your Medicare protections and rights, such as the right to appeal plan decisions.

Advantage plans must include benefits and services covered under Original Medicare Parts A and B. Advantage plans cannot have higher out-of-pocket costs than Original Medicare for chemotherapy, dialysis or skilled nursing facility care.

Original Medicare will cover hospice care and certain costs for clinical research studies even if you purchase an Advantage plan.

You can sign up for a Medicare Advantage plan regardless of any health problems you may have.

Basic Types of Medicare Advantage Coverage

Even though Advantage plans establish individual rules, there are basically four categories of Advantage plans available. Those are health maintenance organization (HMO) plans, preferred provider organization (PPO) plans, private fee-for-service (PFFS) plans, and special needs plans (SNP). Let’s see how they’re different.

Can I use any doctor, hospital or other health care provider?

Original Medicare approves providers and providers decide whether to accept Medicare payment rates. Not all will accept new Medicare patients.

With a PFFS Advantage plan, you can see any Medicare-approved provider who accepts the plan’s payment terms. Certain PFFS plans establish a network of providers who contract to treat you. You can also use providers from outside the network, but your out-of-pocket costs may be higher if you do.

PPO Advantage plans also provide more coverage when you use in-network providers, but still offer some coverage if you need an out-of-network provider.

HMO and SNP Advantage plans usually restrict coverage to in-network services with these exceptions: emergency care, out-of-area urgent care, and out-of-area dialysis. Certain HMO plans have a point-of-service option that allows you to use out-of-network services, but that usually comes at a higher cost.

Do I have to choose a primary care doctor?

You usually are required to select a primary care doctor with an HMO or SNP Advantage plan. You’ll also need a referral from that doctor before seeing a specialist. Some services like mammogram screenings do not require a referral. PFFS and PPO Advantage plans don’t require you to choose a primary care doctor or get referrals.

Are prescriptions covered?

SNP Advantage plans must cover prescriptions, and most HMO and PPO plans do, too. PFFS plans may, but if your plan doesn’t, you can add a Part D prescription plan. You may have to pay higher-than-normal Part D premiums if you join after you first become eligible for Medicare.

If you have an Advantage plan that covers prescriptions and you join a Part D plan, you’ll be dropped from the Advantage plan and enrolled in Original Medicare. Part D plans only work with Original Medicare.

Advantage plans and Part D plans are not required to cover every possible prescription, so be sure to confirm that the plan you’re considering covers what you need before you apply.

When to Join a Medicare Advantage Plan

The AEP (annual election period) is when Medicare recipients have the option to either purchase or change a Medicare Advantage or prescription drug plan. AEP enrollment applies specifically to Medicare Advantage plans, prescription drug plans and Medicare Advantage plans with prescription coverage. Policies purchased during the AEP time period will begin providing coverage on January 1 of the following year.

When to join a Medicare Advantage plan:

1. Every year during the AEP period, which lasts from October 15 to December 7, you will be able to join or change Advantage plans.
2. If you receive disability benefits, you may join an Advantage plan from three months before to three months after the 25th month of disability.
3. If you’re turning 65, you also have a seven-month period to join. That’s from three months before to three months after the month in which you turn 65.
4. You may also be allowed to join when you qualify for Extra Help or Medicaid, if you move to an institution like a nursing home, or if you move out of your existing plan’s service area.
5. You can also switch to an Advantage plan that has a five-star rating once from December 8 through November 30 of the following year.

If you are on a transplant waiting list or think you may need a transplant, check with plan representatives before joining to confirm the plan will cover the doctors, other health care providers, and the hospitalization you’ll need. And be sure you understand plan rules about prior authorization.