Medicare Advantage Frequently Asked Questions
Medicare Advantage FAQ
Medicare Advantage FAQ's
Medicare Advantage plans are private health plans, such as HMOs or PPOs, that are offered by health insurers that have contracts with the Medicare program to offer benefits to people with Medicare. The plans provide all Medicare-covered benefits under Parts A and B, and usually provide Part D prescription drug benefits as well. Some Medicare Advantage plans may also provide benefits that are not covered under traditional Medicare, such as eyeglasses, some dental care, or gym memberships. The plans also have a limit on out-of-pocket spending for services covered under Parts A and B, and may have lower cost-sharing than traditional Medicare for Medicare-covered services. However, Medicare Advantage plans restrict the health care providers that their enrollees can see (provider networks) whereas beneficiaries in traditional Medicare may see any doctor that accepts Medicare, without needing prior authorization or a referral from their primary care doctor.
Medicare Part C plans, also known as Medicare Advantage plans, are private health insurance plans, mainly HMOs and PPOs, for people enrolled in Medicare. If you enroll in a Medicare Advantage plan, you still have Medicare, but you get all of your Medicare-covered benefits through a private plan. Most Medicare Advantage plans also cover prescription drugs and may cover other services, such as vision, dental, and hearing benefits. If you have Part A and Part B already, and are covered under the traditional Medicare program, then you do not need to sign up for a Medicare Advantage plan during Open Enrollment unless you want to get your Medicare benefits through a private plan.
There are two primary ways that you can shore up your Original Medicare benefits. You can enroll in a Medigap plan which will pay after Medicare. This covers some or all of the gaps depending on the plan you choose. Your other option is a Part C Medicare Advantage plan. These plans are private insurance policies which pay instead of Medicare. When you enroll, you agree to use their network and pay copays for services as you go along.
No, Medicare Advantage plans charge the same premiums to all enrollees; they are not permitted to vary premiums based on age, smoking history, gender, or pre-existing medical conditions.
Yes. You will have to pay your monthly Medicare Part B premium to Medicare alongside the monthly premium you pay to your Medicare Advantage plan or Medigap plan.
No, each plan may have a unique list of covered drugs. The list of covered drugs is known as a formulary. Medicare requires all Medicare Part D plans to cover at least two medications in each therapeutic category/class approved by Medicare. The drugs within the formulary are assigned to tiers. The tier determines the co-payment or out-of-pocket costs a person within the plan will pay for the drug. If you take a medication that is not covered on your Part D plan’s formulary, you will pay full retail price.
There are four main types of Medicare Advantage plans, but Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO) plans are the most common types. Here is a comparison of the two varieties:
- HMO plans require that beneficiaries see health-care providers, doctors, and hospitals within the plan’s network except in urgent and emergency situations. In some plans, known as HMO Point-of-Service (HMO-POS) plans, beneficiaries may be able to go out-of-network for certain services, but may have to pay a higher cost.
- PPO plans do not require that beneficiaries use in-network providers and do not require a referral to see a specialist.
- HMO plans may require that beneficiaries choose a primary care physician.
- PPO plans do not require that beneficiaries choose a primary care physician.
- Both HMO and PPO plans generally include prescription drug coverage through a Medicare Advantage Prescription Drug plan (MAPD).
You will need to choose a primary care doctor upon enrolling into most HMO plans, and most of the time this doctor will have to refer you to see a specialist. Some services, like yearly screening mammograms, do not require a referral.
Prescription drugs are covered under most HMO plans called Medicare Advantage Prescription Drug plans. Check with the plan you’re interested in first if you want it to include Medicare Part D prescription drug coverage.
If your physician leaves the plan’s network of providers, you will be notified of his or her departure. You can then select another doctor from within the plan’s network.
Another thing to remember is that if you use an HMO, you agree to receive coverage within that plan’s network except in urgent and emergency situations. You can still receive health care outside of the plan’s network, but be aware that the plan may not pay for these services.
Medicare Advantage PPO plans provide another managed-care option for beneficiaries who want greater provider flexibility. With a PPO plan, your out-of-pocket costs will generally be lower if you use doctors and hospitals in the plan’s preferred provider network. You may also choose to use out-of-network providers, but your copayment and coinsurance costs may be higher.
As mentioned, PPOs don’t require members to have primary care doctors, and referrals aren’t needed before seeing a specialist. If you prefer the convenience of getting specialist care directly, without needing a referral from a primary care physician, this may be one factor to consider when choosing between an HMO or PPO plan.
Like HMOs, you can get Medicare prescription drug coverage through your PPO plan by enrolling in a Medicare Advantage Prescription Drug plan. Keep in mind that not every PPO plan includes prescription drug benefits, and costs and benefits may vary by plan.
Medicare plans are rated on a scale of 1 to 5, with a 5-star rating being the highest score a plan can receive. More stars indicate better performance and quality:
- 5-star rating: Excellent
- 4-star rating: Above Average
- 3-star rating: Average
- 2-star rating: Below Average
- 1-star rating: Poor
For Medicare plans providing health coverage, such as Medicare Advantage or Medicare Cost plans, each plan is given an overall summary rating based on how it performs across five main categories:
- Staying healthy: Plans are rated on whether members had access to preventive services to keep them healthy. This includes physical examinations, vaccinations like flu shots, and preventive screenings.
- Chronic conditions management: Plans are rated for care coordination and how frequently members received services for long-term health conditions.
- Member experience: Plans are rated for overall satisfaction with the health plan.
- Member complaints: Plans are rated on how frequently members submitted complaints or left the plan, whether members had issues getting needed services, and whether plan performance improved from one year to the next.
- Customer service: Plans are rated for quality of call center services (including TTY and interpreter services) and processing appeals and new enrollments in a timely manner.
For Medicare Part D stand-alone Prescription Drug Plans and Medicare Advantage plans that include drug coverage, Medicare star ratings are also based on the following criteria:
- Member experience
- Member complaints
- Customer service
- Drug safety and drug pricing accuracy
The drug safety score is based on factors such as how accurate the plan’s pricing information is and how often members with certain medical conditions are prescribed drugs in a way that is safer and clinically recommended for their condition. Plans are also rated for whether drug pricing information on Medicare Part D Prescription Drug Plan and Medicare Advantage Prescription Drug plan websites is up-to-date and accurate. In addition, the percentage of plan members who got prescriptions for certain drugs with a high risk of serious side effects when there may have been a safer drug choice is also reviewed and scored.
The overall rating gives a quick summary of a plan’s performance, but you can also look up how the plan scored for individual areas within the above main categories. For more information on the criteria Medicare considers when rating its plans, visit Medicare.gov.
Keep in mind that plan ratings can change from year to year and are updated every fall. If you are enrolled in a Medicare plan, be sure to check the Medicare star ratings every fall so you can make an informed decision about whether to stay on the plan or switch to a different plan.
You might have been searching for Medicare Advantage plans available in your zip code and found a plan with a $0 monthly premium. This plan may appear to be “free” in the way that you don’t have to pay an additional monthly amount to be covered by the plan. You generally still have to pay your Medicare Part B premium, however.
Keep in mind that Medicare Advantage plans are offered by private insurance companies which generally do business to make a profit. In order to offer $0 premium plans, they may charge in other ways, such as copayments/coinsurance. A copayment or coinsurance is an amount you pay whenever you receive a service (such as a doctor visit or an emergency room trip) or pick up a prescription drug. In fact, plans with lower premiums or $0 premiums may have higher copayments/coinsurance.
Another way a $0 premium Medicare Advantage plan may cost you is with a deductible. A deductible is an amount, for example $1,000, that you must pay out of pocket before your Medicare Advantage plan begins to pay your medical bills. Most Medicare Advantage plans have separate medical and prescription drug deductibles. You may have a $0 medical deductible, for example, but a $250 prescription drug deductible. Some Medicare Advantage plans have both $0 premiums and $0 deductibles.
The out-of-pocket maximum for Medicare Advantage plans is not a deductible; it is the highest yearly amount you will have to pay out of pocket for covered health-care services. This spending maximum is one important difference between Medicare Advantage plans and the traditional fee-for-service Medicare program; Original Medicare doesn’t have a yearly cap on your health-care costs.
This yearly cap does not include monthly premiums, but annual deductibles, coinsurance, and copayments may all count towards this maximum limit. The out-of-pocket maximum may be different for each individual Medicare Advantage plan and can change from year to year. Once you have reached the plan’s spending limit for that year, then your Medicare Advantage plan will cover 100% of covered health-care costs for the rest of the year.
An out-of-pocket maximum is a limit on the amount you pay for medical bills. This amount may vary year to year, and among plans. Knowing you have a maximum can be very reassuring. If you have a $50,000 surgery, for example, your out-of-pocket costs will generally be significantly less than that if you have a Medicare Advantage plan.
Usually amounts you spend on coinsurance or copayments for covered services count towards your out-of-pocket maximum. For example, if you visit a primary care doctor and pay $10 and visit the emergency room and pay $100, these amounts will generally count towards your out-of-pocket maximum.
Costs that typically do NOT count towards your out-of-pocket maximum include:
- Bills from out-of-network health-care providers
- Services not covered by the plan
Original Medicare, Part A and Part B, does not cover any of the costs associated with gym memberships or fitness programs. However, there are other Medicare plan options that may cover the cost of a gym membership.
Medicare Advantage plans must offer at least the same amount of coverage as Original Medicare (besides hospice care, but that’s still covered under Medicare Part A), and may also offer additional benefits. These extra benefits could include gym membership. If you sign up for a Medicare Advantage plan, you’re still in the Medicare program and need to continue paying your Medicare Part B premium, as well as any premium the Medicare Advantage plan may charge.
On the other hand, Medicare Supplemental plans do not typically include fitness membership.
Because these Medicare plan options are offered through private, Medicare-approved insurance companies, their availability and benefits may differ by location. You may want to compare plans to see if one in your area offers coverage for health club membership costs.
The annual Medicare Open Enrollment period begins on October 15 and continues until December 7. For 2020 coverage, open enrollment will run from October 15, 2019, to December 7, 2019.
During the annual enrollment period (AEP) you can make changes to various aspects of your coverage.
- You can switch from Original Medicare to Medicare Advantage, or vice versa.
- You can also switch from one Medicare Advantage plan to another, or from one Medicare Part D (prescription drug) plan to another.
- And if you didn’t enroll in a Medicare Part D plan when you were first eligible, you can do so during the general open enrollment, although a late enrollment penalty may apply.
If you want to enroll in a Medicare Advantage plan, you must meet some basic criteria.
- You must be enrolled in Medicare Part A and B.
- You must live in the plan’s service area.
- You cannot have End-Stage Renal Disease (some exceptions apply; ESRD patients will be able to enroll in Medicare Advantage plans as of 2021, under the terms of the 21st Century Cures Act).
Between January 1 and March 31 each year, if you are enrolled in a Medicare Advantage plan, you can leave your plan and return to Original Medicare, and buy a Part D prescription drug plan to supplement your Original Medicare. As of in 2019, you also have the option to switch to a different Medicare Advantage plan during this time. From 2011 through 2018, there wasn’t an option to switch to a different Medicare Advantage plan outside of the fall open enrollment period unless you had a circumstance that allowed you a Special Enrollment Period. But the 21st Century Cures Act (Section 17005) expanded the timeframe of the window (from one and a half months to three months) starting in 2019, and allows people to switch from one Medicare Advantage plan to another.
Only one switch during this time frame is allowed each year — you can change your mind multiple times during the enrollment period in the fall, but can only switch to a different Medicare Advantage plan (or back to Original Medicare) once in the first quarter of the new year. But if you sign up for a Medicare Advantage plan in the fall and then decide you don’t like it once it takes effect in January, you have until the end of March to make a change.
You can only sign up for Part D coverage during the first three months of the year if you’re switching from a Medicare Advantage plan back to Original Medicare. You cannot, for example, be enrolled in Original Medicare with a Part D plan and then switch to a different Part D plan during the January — March enrollment period. Instead, you’d need to make that change during the fall election period (October 15 to December 7).
You may switch Medicare Advantage and Part D plans every year during the annual Medicare Open Enrollment period (October 15 through December 7), and, if you are enrolled in a Medicare Advantage plan, you can also switch during the Medicare Advantage Open Enrollment period (January 1 through March 31). It is generally a good idea to compare your plan options every year, even if you are happy with your current coverage, since plans often make changes to their benefits, cost sharing, premiums, and/or provider networks from one year to the next. In addition, you may find another plan that meets your needs better than your current plan if your health needs have changed during the year.
Not necessarily. You will need to contact the company that is offering your plan to find out if/which benefits are available out-of-state. If your plan does not offer out-of-state coverage, there may be another plan offered by the same firm that does, or a similar plan offered by another firm in your area. If you decide that you would like to switch to a different plan, however, note that you will need to wait until the annual Medicare Open Enrollment period (October 15-December 7). You can also use the annual Medicare Advantage Open Enrollment period (January 1-March 31) to switch to a different Medicare Advantage plan or switch to traditional Medicare.
Yes. You can change Medicare Advantage plans or switch to traditional Medicare between October 15 and December 7 each year. You can also use the annual Medicare Advantage Open Enrollment period (January 1-March 31) to switch to a different Medicare Advantage plan or switch to traditional Medicare.
There are a couple of ways to find out if your doctor is in a Medicare Advantage plan network. If you have a particular plan or insurer that you’re looking into, you can go to the plan’s website and look for their searchable directory or find a plan directory on the website, where you can search for your doctor. You may also contact your provider directly to see if they participate in any Medicare Advantage plans. You should then verify with the plan(s) that the doctor is, in fact, in their network.
If you’re already in a Medicare Advantage plan and you want to switch to traditional Medicare, you should contact your current plan to cancel your enrollment and call 1-800-MEDICARE (1-800-633-4227). Note there are specific enrollment periods each year to do this. The first period when you can switch from your Medicare Advantage plan to traditional Medicare is during the Medicare Open Enrollment period that runs October 15 to December 7. When you make the switch back to traditional Medicare during the Medicare Open Enrollment period, the change will take effect on January 1 of the following year. The second period you can switch from Medicare Advantage to traditional Medicare is during the Medicare Advantage Open Enrollment Period that runs from January 1 to March 31. If you switch to traditional Medicare and you want prescription drug coverage through Medicare, you will also need to sign up for a stand-alone prescription drug plan (PDP) for your drug coverage.
If your current Medicare Advantage plan is not being offered next year and you do not choose another plan, you will be enrolled by default in traditional Medicare. In this case, you will need to select a Part D prescription drug plan (PDP) if you want Medicare drug coverage, unless you have drug coverage from another source of coverage (for example, the VA or from your former employer or union).
If you would prefer to stay enrolled in a Medicare Advantage plan, you may shop around and enroll in a new plan during the Medicare Open Enrollment period, which runs from October 15 through December 7. Note that when a plan is discontinued, you will typically qualify for a Special Enrollment Period (SEP), which gives you more time to enroll in a new plan outside of the annual Medicare Open Enrollment period. If you receive notice that your plan is not being renewed in the following year, you will have from the first day of the Medicare Open Enrollment period (October 15) through the last day in February of the following year to select a new plan or switch to traditional Medicare. You can also use the annual Medicare Advantage Open Enrollment period (January 1-March 31) to switch to a different Medicare Advantage plan or switch to traditional Medicare.
If you enroll in a plan during the Medicare Open Enrollment period that runs from October 15 to December 7 each year, your coverage takes effect on January 1 of the following year.
No, you do not need to do anything during the Medicare Open Enrollment period if you like your current Medicare Advantage plan, as long as it continues to be offered the following year. However, it is still a good idea to compare your plan options each year, since plans often make changes to their benefits, cost-sharing, premiums, and/or provider networks from year-to-year. By comparing your current plan to others available in your area, you can confirm that your plan is still the best plan for you.
An HMO-POS plan has features of an HMO plan. One is a defined list of providers, often referred to as a network, that members must use for care and services. The plan may require the member to have a primary physician who coordinates care and there may be prior authorization requirements.
However, there is one big difference. An HMO-POS plan allows members to use healthcare providers that are outside the plan’s network for some or all services. For example, one HMO-POS plan will cover out-of-network hospitalization but not mental health care. In most cases, a referral from the primary physician is required and authorization may be necessary. The plan has separate deductibles and out-of-pocket limits for in- and out-of-network services.
The member will pay more for out-of-network services and the plan may limit use. However, this option provides an element of flexibility not available with an HMO plan.
Generally, you can only change your plan or enroll in a new one during specific times. Special Enrollment Periods are periods of time outside normal enrollment periods, triggered by specific circumstances. If you want to enroll in a plan or change plans, you can take advantage of a SEP to join or switch to a five-star Medicare Advantage or Part D plan. This means that you can enroll in a Medicare Advantage Plan or stand-alone Part D plan in your service area that has an overall plan performance rating of five stars. You may only use this SEP once per calendar year.
This SEP begins December 8 of the year before the plan is considered a five-star plan (remember that ratings come out in October) and lasts through November 30 of the year the plan is a five-star plan
Enrollments in December are effective January 1
Enrollments from January to November are effective the month following the enrollment request