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Medicare Advantage

Medicare Advantage Plans are run by private companies, which combine Medicare Part A and B benefits all in one plan.

What If You Have Medicare Advantage Plan?

If you have a Medicare Advantage Plan, here are a few things you need to know:
  • You're still in the Medicare Program.
  • You still have Medicare rights and protections.
  • You still get complete Part A and Part B coverage through the plan.
  • You can only join a plan at certain times during the year, or under special circumstances. In most cases, you're enrolled in a plan for a year.
  • You can join a Medicare Advantage Plan if End-Stage Renal Disease (ESRD), but a certain criteria has to be met.
  • You can check with the plan before you get a service to find out if it's covered and what your costs may be.
  • You must follow plan rules, like getting a referral to see a specialist to avoid higher costs if your plan requires it. The specialist you're referred to must also be in the plan's network. Check with the plan.
  • If you go to a doctor, other health care provider, facility, or supplier that doesn't belong to the plan's network, your services may not be covered, or your costs could be higher. In most cases, this applies to Medicare Advantage HMOs and PPOs.
  • Providers can join or leave a plan’s provider network anytime during the year. Your plan can also change the providers in the network anytime during the year. If this happens, you may need to choose a new provider.
  • If you join a clinical research study, some costs may be covered by your plan. Call your plan for more information. Get your plan's contact information from a Personalized Search (under General Search), or search by plan name.
  • Medicare Advantage Plans can't charge more than Original Medicare for certain services like chemotherapy, dialysis, and skilled nursing facility care.
  • Medicare Advantage Plans typically have a yearly limit on your out-of-pocket costs for medical services. Once you reach this limit, you’ll pay nothing for covered services. This limit may be different between Medicare Advantage Plans and can change each year. You should consider this when choosing a plan.
  • If the plan decides to stop participating in Medicare, you'll have to join another Medicare health plan or return to Original Medicare.

Who is Eligible for Medicare Advantage Plans?

You are eligible to join a Medicare Health Maintenance Organization (HMO), Preferred Provider Organization on (PPO), Private Fee-for-Services (PFFS) or Medicare Medical Savings Accounts (MSA) if you meet the following conditions:
  • You live in the service area of the plan you want to join. The plan can give you more information about its service area. If you live in another state for part of the year, check to see if the plan will cover you there.
  • You have Medicare Part A and Part B.
  • You don't have End-Stage Renal Disease (ESRD), or an exception applies.

Can I drop or switch a Medicare Advantage Plan?

You are allowed to switch Medicare Advantage Plan.  Follow these steps if you're already in a Medicare Advantage Plan and want to switch:
  • To switch to a new Medicare Advantage Plan, simply join the plan you choose during one of the enrollment periods. You'll be disenrolled automatically from your old plan when your new plan's coverage begins.
  • If you want to leave your Medicare Advantage Plan, you must request disenrollment from the plan and then you will automatically receive your benefits through Original Medicare. Unless you have other drug coverage, you should carefully consider Medicare prescription drug coverage (Part D). You may also want to consider a Medicare Supplement Insurance (Medigap) policy.  Remember, you may only be able to switch at certain times of the year.
Each year, you have a chance to make changes to your Medicare Advantage or Medicare prescription drug coverage for the following year.  There are 2 separate enrollment periods each year.
  1. Open Enrollment Period (October 15–December 7) for Medicare Advantage and Medicare prescription drug coverage. Under Open Enrollment Period you can:
  • Change from Original Medicare to a Medicare Advantage Plan.
  • Change from a Medicare Advantage Plan back to Original Medicare.
  • Switch from one Medicare Advantage Plan to another Medicare Advantage Plan.
  • Switch from a Medicare Advantage Plan that doesn't offer drug coverage to a Medicare Advantage Plan that offers drug coverage.
  • Switch from a Medicare Advantage Plan that offers drug coverage to a Medicare Advantage Plan that doesn't offer drug coverage.
  • Join a Medicare Prescription Drug Plan.
  • Switch from one Medicare drug plan to another Medicare drug plan.
  • Drop your Medicare prescription drug coverage completely.
  1. Medicare Advantage Disenrollment Period (January 1–February 14). Under Medicare Advantage Disenrollment period you can do the following:
  • If you're in a Medicare Advantage Plan, you can leave your plan and switch to Original Medicare.
  • If you switch to Original Medicare during this period, you'll have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Your coverage will begin the first day of the month after the plan gets your enrollment form.
  • To switch to Original Medicare, contact your current plan, or call 1-800-MEDICARE.

What if You Have Other Health Care Coverage?

Talk to your employer, union or other benefits administrator about their rules before you join a Medicare Advantage Plan. In some cases, joining a Medicare Advantage Plan might cause you to lose your employer or union coverage. If you lose coverage for yourself, you may also lose coverage for your spouse and dependents.
In other cases, if you join a Medicare Advantage Plan, you may still be able to use your employer or union coverage along with the plan you join. Remember, if you drop your employer or union coverage, you may not be able to get it back.