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Medicare FAQs - Medicare Advantage Plans Overview

1.What is a Medicare Advantage plan?

Medicare Advantage plans are health plan options approved by Medicare and administrated by private companies. Some Medicare Advantage plans offer drug coverage.

2. Are Medicare Advantage plans considered Medigap plans?

No. Medigap plans are purchased to supplement original Medicare. Medigap plans pay for cost-sharing charges. Essentially, these plans "cover the gaps" in Original Medicare coverage.

Medicare Advantage plans actually replace Original Medicare. When a beneficiary opts to enroll in a Medicare Advantage plan, the privately administered plan provides their Medicare coverage. By law, Medicare Advantage plans must cover everything covered under Traditional Medicare Parts A and B. Medicare Advantage plans may also offer additional benefits, (such as dental or vision coverage), and prescription drug coverage.

3. Do I need a Medigap policy if I choose to enroll in a Medicare Advantage plan?

No. When you enroll in a Medicare Advantage plan, Medigap will not cover Medicare benefits nor any health plan deductibles, coinsurance or co-pays for you.

4. When can I enroll in a Medicare Advantage plan?

When first eligible for Medicare at age 65 or after you have been receiving SSDI for 24 months:

  • You can enroll three months before you turn 65, during the month of your 65th birthday and for three months after and still have your coverage effective on the day you first became eligible (usually the first of the month after your 65th birthday).
  • If you are under 65 and become eligible for Medicare due to disability, you can enroll in Medicare three months before the month of and three months after you have been getting SSDI for 24 months.

Annual enrollment:

  • Each year, from Oct. 15 - Dec. 7, you can change plans, with the change effective Jan. 1 of the following year.

Special enrollment periods (when certain criteria are met):

  • Special enrollment rules allow you to drop, add or change plans under certain circumstances. For example, if you move out of a plan's service area, have both Medicare and Medicaid, live in an institution as defined by CMS to be a long-term care facility such as a skilled nursing facility (but not an assisted living or residential home), or are a member of a special needs plan (SNP), you can change plans as needed. Also, if you feel you have been misled when you joined a plan, you can request that CMS allow you to change plans, even if it is outside the open enrollment period.

5.Once I enroll in a Medicare Advantage plan, when does it become effective?

Your effective date will depend upon which enrollment period applies to you.

  • If you enrolled when you were first eligible for Medicare, your effective date will be retroactive to the date of your eligibility.
  • If you enrolled during a regular annual election period, your effective date will be January 1 of the following year.
  • If you enrolled during the open enrollment period, your effective date will generally be the first day of the month after which the Medicare Advantage organization received your enrollment form.
  • If you enrolled during a special enrollment period, your effective date may vary depending upon your circumstances.

If you choose to enroll in a Medicare Advantage organization, you should ask them when your effective date will be.

6. Do Medicare Advantage plans cover emergency or urgently needed care?

Yes, all plans must cover all Medicare Parts A and B services, including emergency and urgently needed care.

7. When do plan coverage details change for Medicare Advantage plans?

The private insurance company's contract with CMS to administer a Medicare Advantage plan is on a calendar year. This means plan benefits and rules changes can occur annually, effective January 1 of each year. If you are enrolled in a Medicare Advantage plan, they are required to send you notification of any plan changes that may occur in advance so you can make a decision as to what to do.

8. Will I receive written confirmation of my Medicare Advantage plan benefits?

Yes. When you are newly enrolled, you will receive a letter from the plan letting you know your enrollment was successful. If the plan needs more information to finish processing your enrollment, they will let you know in writing. Also, at the time you enroll and every year that you're a member of the plan, the Medicare Advantage plan will send you an Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) explaining the plan rules, letting you know how much your coverage will cost and providing you with any information on benefit changes that will be effective in January of the next year. The EOC is available on the Medicare Advantage plan's Web site as well.

9. Which Medicare Advantage plans do not offer prescription drug coverage?

Some plans, such as Medicare medical savings accounts and certain Medicare private fee-for-service (PFFS) plans, do not offer prescription drug coverage. Because the Medicare Advantage plans are administrated by private companies, they vary widely. It is very important to ask questions about prescription drug coverage.

10. What happens if the Medicare Advantage plan selected does not offer prescription drug coverage?

If a Medicare Advantage plan does not offer drug coverage, you may be able to join a Medicare prescription drug plan (Part D).

11. Do Medicare Advantage plans have deductibles?

Medicare Advantage plans are approved by Medicare and administered through many different private insurance companies. Because they are privately run, costs may differ from plan to plan, but anyone who joins a Medicare Advantage plan will pay the same cost as all other members regardless of medical condition. It is important that you check into the costs for each Medicare Advantage plan you are considering.

12. What type of costs can I expect with a Medicare Advantage plan?

Medicare Advantage plans vary, but there are some expenses you may be responsible for, including:

  • Premiums: There may be a monthly plan member premium. This is a set amount approved by CMS that the Medicare Advantage plan charges the beneficiary for membership. Members pay the Medicare Advantage premium in addition to their Part B premium. Some plans offer the option of automatically deducting the premium from a member's Social Security check.
  • Deductible: Some Medicare Advantage plans require beneficiaries to pay a certain amount before their plan begins to pay a portion of the costs. This amount is referred to as the deductible.
  • Co-payments: As with regular insurance plans, you will pay a portion of the cost for the services or prescription drugs you use. Some Medicare Advantage plans charge members a co-payment, or flat fee, for medical services, like doctor's appointments and hospital stays. If you have a Medicare Advantage plan that includes prescription drugs, you may also pay a co-payment for any medicines you buy.
  • Coinsurance: Medicare Advantage plans can choose to charge members co-insurance instead of a co-payment. While a co-payment is a flat fee, co-insurance is a percentage of the cost of the medical service or prescription drug purchased.If you choose a plan that charges coinsurance instead of a c-opayment, your costs may vary depending upon the cost of the medical service or prescription drug (if you've chosen a Medicare Advantage plan with drug coverage) provided.

13. Does everyone pay the same amount for Medicare Advantage plan membership?

The only exception is those members with Medicare and Medicaid who may be able to pay less or those who are eligible for low-income subsidy (LIS).

14. When can you join, switch or drop a Medicare Advantage plan?

You can join, switch or drop a Medicare Advantage plan:

  • When you first become eligible for Medicare (three months before you turn 65 and up to three months after the month you turn age 65).
  • If you get Medicare due to a disability, you can join during the three months before and up to three months after your 25th month of entitlement to cash disability benefits.
  • From Oct. 15 - Dec. 7 of each year. Your coverage will begin on Jan. 1 of the following year.
  • In certain situations, you may be able to join, switch or drop Medicare Advantage plans at other times (like if you move out of the service area, have both Medicare and Medicaid or live in an institution).

15. What happens if my Medicare Advantage plan leaves the Medicare Program?

If your plan leaves the Medicare program, the plan will send you a letter about your options. Generally, you will be automatically returned to Original Medicare if you don't choose to join another Medicare Advantage plan. You also will have the right to purchase a Medigap policy.

16. What are the special rules regarding eligibility for people with ALS (Amyotrophic Lateral Sclerosis or Lou Gehrig's disease)?

People with ALS automatically get Medicare Part A and Part B the month their disability benefits begin.

17. What is not covered by Part A and Part B?

  • Acupuncture
  • Chiropractic services, except to correct a subluxation (when one or more of the bones in the spine move out of position) using manipulation of the spine
  • Cosmetic surgery
  • Custodial care (like help with bathing or using the bathroom) except when you also get skilled nursing care in a skilled nursing facility, at home or in a hospice
  • Deductibles, coinsurance or co-payments for certain healthcare services
  • Dental care and dentures
  • Eye care, eye exams (except for people with diabetes to check for diabetic retinopathy), eye refractions and eyeglasses (except after cataract surgery that implants an intraocular lens)
  • Foot care (routine), such as cutting corns or calluses
  • Hearing aids and exams for the purpose of fitting a hearing aid
  • Hearing tests that haven't been ordered by a doctor
  • Certain laboratory tests
  • Long-term care for custodial care in a nursing home
  • Orthopedic shoes
  • Prescription drugs
  • Syringes or insulin, unless the insulin is used with an insulin pump, but it may be covered by Medicare prescription drug coverage (Part D)
  • Healthcare while traveling outside the United States except when you travel on the most direct route through Canada between Alaska and another state. Medicare also covers hospital, ambulance and doctor services if you are in the U.S., but the nearest hospital that can treat you isn't in the United States. The "United States" includes the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands and American Samoa. In some limited cases, Medicare may pay for services you get while on board a ship within the territorial waters adjoining the land areas of the United States.

18. Are the services listed above covered by Medicare Advantage plans?

Medicare Advantage plans are approved by Medicare and administered through many different private insurance companies. Some Medicare Advantage plans may provide certain of the above services as part of an enhanced benefit, but it is important that you check the plan details for covered services, especially if it is a service that you use on a regular basis.

19. Who can join a Medicare Advantage plan?

In order to join a Medicare Advantage plan, you must have Medicare Parts A and B and live in the plan service area at least six months of the year.

20. What benefits are offered in a Medicare Advantage plan?

All Medicare Advantage plans must cover all Medicare Parts A and B services, including emergency and urgently needed care. In addition, Medicare Advantage plans generally cover most of the original Medicare cost-sharing such as coinsurance and deductibles and also may cover other services such as vision and wellness programs. Benefits vary from plan to plan so it is important to check with the plan administrator about coverage before selecting a plan.

21. What impact does employer/retiree coverage have on Medicare Advantage plans?

Employer/retiree coverage is based on rules specific to each employer. An employer may choose not to offer any retiree benefits. They also may choose to offer coverage through a specific health plan or payment toward health plan premiums. Employers' rules regarding insurance coverage can vary. Joining a Medicare Advantage plan not sponsored by the employer may cause you to lose not only health insurance, but also other employer benefits. Once the employer coverage is dropped, you may be restricted from returning to the employee/retiree insurance coverage. Great care must always be taken when deciding on a Medicare plan.

22. If I drop Medicare Advantage, will I be able to get Medigap insurance?

The first time Medigap coverage is dropped to join a network Medicare Advantage plan, you have a one-time right to return to Medigap. After the first time, you do not have an automatic right to return to Medigap.