Click HERE for the official government booklet on Medicare Advantage plans.
Part C – Is another name for Medicare Advantage Plan
MA – Medicare Advantage (no drug coverage) in this plan.
MAPD – Medicare Advantage Prescription Drug Plan (includes drug coverage)
PDP – “Stand-alone” Prescription Drug Plan (for people who have “creditable drug coverage” elsewhere, like the VA)
Can I have a Medicare Advantage (MA) plan AND a Prescription Drug Plan (PDP)
No, PDP plans are ONLY available to people on Original Medicare (or original Medicare and a Medigap plan). If you want to have a Medicare Advantage plan with drug coverage, you need to get a MAPD plan.
Why would anyone get a Medicare Advantage (MA) plan “only” since it doesn’t include drug coverage and Medicare beneficiaries are always required to have some sort of a drug plan?
Great question! It is possible they are receiving “creditable” drug coverage from elsewhere like the Veterans Administration, Federal Employee Health Benefits (FEHB) program, TRICARE or Indian Health Services (IHS). People with creditable coverage should receive a notice from the source of that coverage letting you know that your coverage is, in fact, “creditable”. You should keep this notice in case you need to show proof that you had creditable coverage if you decide later you want Medicare prescription drug coverage.
With Medicare Advantage will I still have Original Medicare Part A and B?
You will no longer have Original Medicare Part A and Part B when you choose a Medicare Advantage plan. A private insurance company takes over your Original Medicare Part A and Part B and bundles them into a single managed care plan usually an HMO or PPO, similar to what you may have had with employer group coverage. Medicare Advantage plans are regulated by the federal government. The plans must be as good or better than Original Medicare. Medicare Advantage plans are also known as Part C plans.
When can I enroll in a Medicare Advantage plan?
After you activate your Part A and Part B during your Initial Enrollment Period (IEP – 3 months before your 65th birthday, the month of your 65th birthday and up to 3 months after your 65th birthday month). Or, if you “delay” your Part B because you are still working past 65 and receiving “creditable” health coverage from your employer, you can enroll in a Medicare Advantage plan after you eventually retire and activate Part B with Medicare. *NOTE: You must have both Part A and Part B to enroll in a Medicare Advantage or Medigap plan.
What happens if I miss my Initial Enrollment Period (IEP) when I first turn 65 to enroll in Medicare?
Enrolling in a Medicare Advantage or Prescription drug plan is based on enrolling and activating your Part A and Part B effective dates with Medicare. If you miss your Initial Enrollment Period (IEP), you will have to wait and enroll in Medicare’s General Enrollment Period – GEP (January 1st thru March 31st), your coverage will become effective the first of the month following the month you enrolled.
Are there any health questions to qualify for a Medicare Advantage plan?
NO, there are no health questions. This is one of the attractive benefits of Medicare Advantage plans, everyone qualifies.
Do Medicare Advantage plans have a Max-Out-Of-Pocket (MOOP) limit each year?
YES, all Medicare Advantage plans have a Max Out Of Pocket that can vary. The MOOP for 2023 is “up to” $8,300 for in-network expenses.
Do I still have to pay the Medicare Part B premium with a Medicare Advantage plan?
YES, most people have to pay the Standard Part B premium ($164.90 in 2023). If you are collecting Social Security, they will automatically deduct if from your Social Security income. (For more on Part B costs click HERE). (NOTE: some beneficiaries receiving income assistance do not pay the Medicare Part B premium).
When would be the effective date of my Medicare Advantage plan?
The plan effective date will always be the 1st of the month after you enroll. If you enroll during AEP (Oct 15 – Dec 7), the plan effective date will be January 1st of the following year.
Do Medicare Advantage Plans come with Prescription Drug coverage?
Yes, most Medicare Advantage plans include drug coverage. There are plans available without drug coverage. (*NOTE: You would only enroll in a Medicare Advantage plan without drug coverage if you receive “creditable” drug coverage elsewhere, like the VA or Tricare, for example).
Can I have a Medicare Advantage plan and a Medicare Supplement (Medigap) plan at the same time?
NO, you can only have one or the other.
Can I have a Medicare Advantage Plan and a “Stand-alone” Part D Prescription drug plan?
NO, if you have a Medicare Advantage plan and want drug coverage, you must enroll in a Medicare Advantage Prescription Drug plan (MAPD). (NOTE: the “Stand-alone” Part D Prescription drug plan would be for somebody on Original Medicare or Original Medicare with a Medigap plan.
Do I have to select a primary care physician (PCP)?
With an HMO Medicare Advantage plan you usually need to assign a PCP. Normally with a PPO Medicare Advantage plan you do not need to assign a PCP, although it is recommended you do so.
Do all providers accept Medicare Advantage Plans?
No, not all providers and hospitals accept all Medicare Advantage Plans. You need to check with a licensed insurance agent first to be sure that not only is your provider included in the network, but they also take your specific Medicare Advantage Plan. (Example: Some providers may take the PPO plan but not the HMO plan from a particular carrier).
Can I go “outside” of the network?
Generally, with an HMO plan you can NOT go outside the network to receive care (unless it is an emergency). In a PPO plan, you can usually go outside the network but the plan will charge you higher copays and co-insurance to see out-of-network providers.
Do I need a referral from my primary care physician to see a “Specialist”?
Generally HMO plans require a referral to see a specialist. In most cases you do not need a referral to see a specialist on a PPO plan. (Click HERE for more information).
Are Medicare Advantage plans portable?
No, Medicare Advantage plans are “county specific”. If you move to another service area, even in the same state, your current plan may not be available, so you will need to enroll in a new plan in the new location. (You will have a Special Election Period (SEP) to switch to a plan in your new area).
Do Medicare Advantage plans offer their members anything extra?
Many Medicare Advantage plans will include “extras” like routine dental, vision and hearing coverage, gym membership, transportation to doctors, OTC (Over-the-counter) allowance and more.
How long are Medicare Advantage plans and can the plans change?
Medicare Advantage plans are ONE-YEAR plans from January 1 thru December 31. The plans can change every year. It is very important to check the Annual Notice of Change (ANOC) every year (usually mailed out in September, just before Annual Election Period), showing the new changes to your plan for the next year. The plan can change many things including the provider network, drug coverage, pharmacies, copays, etc.
What if I want to drop my Medicare Advantage plan and switch to Original Medicare?
There are specific election periods you must wait until to switch your Medicare plan. Click HERE for more information on joining or switching Medicare plans.
There are some other special circumstances that may qualify you for a “Special Election Period” (SEP). Click HERE for more information.
For more information about Medicare Advantage plans, please click HERE and also HERE.
