Medicare Plans

Medicare Advantage Plan Types and Enrollment Periods

Medicare Advantage Plans (Part C)

A Medicare Advantage Plan (like an HMO or PPO) is another health coverage choice you may have as part of Medicare. Medicare Advantage Plans, also known as "Part C" or "Medicare Replacements," are offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. In all plan types, you are always covered for emergency and urgent care. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you are in a Medicare Advantage Plan. Medicare Advantage Plans aren't considered supplemental coverage.

Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage. In addition to your Part B premium, you may have a monthly premium to pay for your plan (or some Medicare Advantage plans may actually refund a portion of your Part B premium). Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan).

Medicare Advantage Plans include the following:

• Health Maintenance Organization (HMO) Plans
• Preferred Provider Organization (PPO) Plans.
• Private Fee-for-Service (PFFS) Plans.
• Medical Savings Account (MSA) Plans.
• Special Needs Plans (SNP).

When Can You Join, Switch or Dis-enroll from a Medicare Advantage Plan?

Enrolling into Medicare Advantage or switching plans may be done at these times:

• You can join when you first become eligible for Medicare (the 7 month period that begins 3 months before the month you turn age 65, includes the month you turn age 65, and ends 3 months after the month you turn age 65).
• If you get Medicare due to a disability, you can join during the 3 months before to 3 months after your 25th month of disability. You will have another chance to join 3 months before the month you turn age 65 to 3 months after the month you turn age 65.
• Plan changes may be requested during the Annual Election Period, which runs from October 15 - December 7 each year. Your new coverage begins on January 1 of the following year, as long as your enrollment request is received by the plan on time.
• Starting in 2019, a new Medicare Advantage Open Enrollment Period will run from January 1 - March 31 every year. If you're enrolled in a Medicare Advantage plan as of January 1st, you will have a one-time opportunity to switch to a different Medicare Advantage plan.

You can dis-enroll from Medicare Advantage and return to original Medicare during these times:

• During the Annual Election Period (timeframe noted above).
• During the Medicare Advantage Open Enrollment Period (timeframe noted above). You'll have a one-time opportunity to drop your Medicare Advantage plan and return to Original Medicare, Part A and Part B (typically, you can sign up for stand-alone Medicare Part D Prescription Drug Plan if you return to Original Medicare).

What is the difference between the Annual Election Period (AEP) and the Open Enrollment Period (OEP)?

AEP offers more options and flexibility than OEP. For example, during OEP you can join a Medicare Part D drug plan ONLY if you are dropping a Medicare Advantage plan and returning to Original Medicare. However, during AEP, you can make any desired changes to your Medicare drug coverage.

Also, insurers and agents are not permitted to actively market plan changes under the OEP election period. Rather, OEP is intended as an opportunity for Medicare Beneficiaries to make a plan change during the first quarter of any year upon their own initiation of the request. Examples could include provider network problems, formulary issues, or dissatisfaction with the Medicare Advantage plan.

What changes can you make during AEP?

During AEP, you can make changes to your Medicare Advantage and Cost plans, and Part D drug plans only. Multiple changes (the last request is honored) may be made, including:

• Dropping your Medicare Advantage plan and returning to Original Medicare.
• Moving from Original Medicare only to a Medicare Advantage plan.
• Enrolling in a different Medicare Advantage plan.
• Choosing a different Medicare Part D prescription drug plan.
• Adding a Part D prescription drug plan if you don't have one.
• Canceling your current Part D drug plan.
  • Note: If you don't maintain some form of creditable prescription drug coverage and decide to re-enroll in Part D in a later year, you'll face a late-enrollment penalty.

What changes can you make during OEP?

You can make these changes related to your current Medicare Advantage plan only:

• Switching to a different Medicare Advantage plan.
• Dropping your Medicare Advantage plan and returning to Original Medicare.
• Adding a standalone Part D plan – only if you dropped your Medicare Advantage plan and returned to Original Medicare.

The MA OEP happens annually from January 1st through March 31st and only applies to people who have coverage under a Medicare Advantage plan. Also, enrollees can only make one plan change during this annual window (in contrast to the fall AEP when enrollees can change their minds multiple times). When enrolling under OEP, coverage is effective on the 1 st day of the month after applying.

There is no special flexibility to change your Medicare Supplement (Medigap) plan during either AEP or OEP, i.e., the same coverage eligibility rules apply as during the rest of the year. If you have a Medicare Advantage plan and wish to change to Medigap, you should dis-enroll from your Medicare Advantage during AEP and apply for the change in coverage to take place on January 1st (keep in mind you may have to health-qualify for the Medigap coverage). If you enroll in a standalone Part D plan during AEP, your existing Medicare Advantage will be canceled automatically on January 1st.

In most cases following a Medicare Advantage plan change (or return to Original Medicare) during OEP, you must stay enrolled for that calendar year starting the date your coverage begins. However, in certain situations, you may be able to join, switch or dis-enroll from a Medicare Advantage Plan at other times. Some of these situations include the following:

• If you move out of your plan's service area.
• If you have both Medicare and Medicaid ("Dual" eligibility allows you to enroll in a "D-SNP" plan).
• If you have a qualifying chronic condition, such as diabetes or heart disease (presence of the chronic condition may allow you to enroll in a "C-SNP" plan).
• If you qualify for Extra Help (Low Income Subsidy) to pay for prescription drug costs.
• If you live in an institution (such as a Nursing Home).
• If an emergency or disaster has been declared by a Federal, State, or Local Government and you missed another applicable election period due to that disaster (Special Election Period enrollment dates are set forth by the applicable authority).
• The Plan Sponsor has earned a 5-Star Medicare Rating (see below).

Star Ratings And Special Enrollment Periods

Star Ratings

Medicare evaluates plans based on a 5-star rating system. New plan quality ratings are released each October and apply to the next calendar year.

Special Enrollment Periods

Special Enrollment Periods are periods besides the Open Enrollment Period during which beneficiaries can change their Medicare plans. Starting in 2012, there is a different Special Enrollment Period applicable to 5-star rated Medicare Advantage plans. Medicare Advantage Plan Star Performance Ratings are released in the fall each year and apply to the following calendar year. During this Special Enrollment Period, any Medicare beneficiary living in the service area of a 5-star Medicare Advantage plan is able to change to it from December 8 of the year before the plan is considered a five-star. It lasts through November 30 of the year the plan is considered a five-star plan. Enrollments December 8 through December 31 are effective January 1st. Enrollments January 1 through November 30 are effective the month following the month you submit an enrollment request. This Special Enrollment Period may only be used once per year.

Special Enrollment Period For Low Star Rated Plans

Members who are enrolled in a Medicare Advantage Plan that has received less than a 3-Star Rating in three consecutive years are eligible for a Special Enrollment Period. CMS will mail members a notice in late October informing members of this Special Election Period. Members who receive the notice have the remainder of the plan year, as well as the following plan year, to switch to a plan rated 3-Stars or more. To use this Special Election Period, you must call 800-Medicare directly. Coverage will begin the month following the month you submit your Special Election Period enrollment request.

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• When Do I Sign Up for Medicare Parts A & B?
• How Much are Medicare Premiums, Deductibles and Coinsurance Rates?
• Can I Choose Medicare Advantage (Part C) Instead of Medicare Parts A & B?
• Medicare Advantage Plan Types and Enrollment Periods
• Are There Other Kinds of Medicare Health Plans?
• What Are My Options for Medicare Prescription Drug Coverage (Part D)?
• What Are Medigap (Medicare Supplement Insurance) Policies?
• Changes Made to Medigap Plans on June 1st, 2010
• Changes Made to Medigap Plans on January 1st, 2020