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What is Medicare Advantage and what does it cover?


The annual open enrollment period for traditional Medicare may have ended, but there is another open enrollment window for those who are currently enrolled in a Medicare Advantage Plan. 

The Medicare Advantage open enrollment period runs from Jan. 1 to March 31 each year.

Who does this impact?

The Medicare Advantage open enrollment period only applies to those who are already enrolled in a Medicare Advantage plan. This period is not meant for those who are not enrolled in Medicare at all or those enrolled in traditional Medicare parts A and B. Those who are not enrolled in a Medicare Advantage plan must generally wait until the annual Medicare open enrollment period that runs from Oct. 15 to Dec. 7 each year to make changes in their coverage. 

Read: Senators call for Medicare Advantage improvements. Here’s what you can do now.

Original Medicare vs. Medicare Advantage

Original, or traditional, Medicare consists of Medicare Parts A and B. You will need to obtain Part D prescription drug coverage. You may want to obtain a Medigap supplement as well. It is a somewhat al carte approach to Medicare coverage.

On the other hand, Medicare Advantage plans include coverage for Parts A, B and D. There are networks for doctors and other providers, there is also a list of prescription medications and pharmacies that are included in the network. There may also be other services included in the plan coverage. Medicare Advantage is a bundled approach to Medicare coverage. 

What can you do during this open enrollment period?

Those who are already enrolled in a Medicare Advantage plan can:

Switch to another Medicare Advantage (part C) plan

Drop their Medicare Advantage plan and switch to original Medicare (parts A and B)

Those who switch to original Medicare can enroll in a Medicare part D drug plan.

Why would you switch Advantage coverage?

There are a number of reasons that you might decide that your current Medicare Advantage coverage is not right for you.

Have the doctors and other providers available in their Advantage plan changed? Are some of your doctors and providers now excluded from coverage?

Has your health situation changed? Does this change require the care of new doctors and other providers who are not in your Advantage plan’s network?

Perhaps you have been prescribed new medications by your doctor and those medications are not covered by the drug component of your current Advantage plan.

Have you decided to relocate or to reside in a different part of the country for a portion of the year? If so, you might find that your Advantage plan coverage does not extend to your doctors or other providers in this different part of the country.

Plan premiums have increased, copays and deductibles are higher and perhaps some of your medication is not covered under the prescription drug portion of the plan.

These and other reasons might cause you to look for an alternative to your current Medicare Advantage plan.

Moving to another Medicare Advantage plan

One option for those dissatisfied with their current Medicare Advantage plan is to move to another Medicare Advantage plan. Perhaps you like the all-in-one type of coverage offered by an Advantage plan.

If this is the route you want to go, be sure to list out all of the reasons you are considering leaving your current Advantage plan and what features are important to you in finding a new Advantage plan. Review any new plan that you are considering to ensure that it meets all or most of the criteria that you have set.

Moving to original Medicare

In reviewing your health situation you might decide to make the switch from Medicare Advantage coverage to original Medicare. Original Medicare is configured in a different fashion than a Medicare Advantage plan.

Original Medicare consists of Parts A and B. You will need to add a part D prescription drug plan. Medicare recipients need to prove that they have creditable prescription drug coverage within the deadlines set by Medicare or face a penalty. This penalty is permanent and will result in higher ongoing Part D premiums.

Many on original Medicare purchase a Medigap supplement to cover costs like plan deductibles, copays and other costs not covered by parts A, B and D. One potential situation you could face in moving from a Medicare Advantage plan to original Medicare is that insurers providing Medigap supplement policies can charge you a higher rate or deny coverage altogether if you have health issues. This differs from those who enroll in original Medicare during their initial enrollment period, in this case coverage cannot be denied or rates increased due to health issues.

One reason you might consider moving from a Medicare Advantage plan to original Medicare could include the fact that there is no network for doctors or other providers as with an Advantage plan. This eliminates the network and geographic restrictions that a network can create. Also most, but not all doctors and providers will accept the payment levels under Medicare parts A and B, this can reduce costs from added deductibles and copays under an advantage plan.

If you decide to move to original Medicare from an Advantage plan be sure that you have a plan to get coverage for services not covered by parts A, B and D such as dental, hearing and vision coverage.

When does new coverage start?

If you do make a change during the Medicare Advantage enrollment period, coverage will become effective on the first day of the next month after your enrollment is complete. Your new coverage will remain in effect through the end of 2024.

Enrollment periods during the year

For those on Medicare or who will become eligible for coverage, there are a number of enrollment periods during the year to be aware of in addition to the Medicare Advantage open enrollment period.

Initial enrollment period. This seven-month period is for those new to Medicare and extends for three months before and three months after your birth month plus your birth month. This generally starts surrounding your 65th birthday. For those who are covered by other coverage such as an employer plan, their initial enrollment period will vary.

Annual Medicare Open Enrollment period. This extends from Oct. 15 through Dec. 7 each year and allows anyone on Medicare to switch their coverage for the following year.

Special enrollment periods cover various situations and allow Medicare recipients to adjust their coverage as needed.

For those approaching age 65 or those who are already on Medicare it is critical to understand all enrollment periods and when you are required to have coverage in order to avoid penalties or coverage lapses. 

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