What is a Medicare Advantage Plan?

Medicare Advantage (MA) Plans are health plan options with a Medicare contract that are offered to Medicare beneficiaries. These plans are offered by private insurance companies and are available in many areas across the country depending on the state and zip code.

Medicare Advantage plans are required to cover everything that is covered under Medicare Part A and B, but some may offer additional benefits that are not covered under Original Medicare such as prescriptions, dental, vision, and hearing.

When a beneficiary enrolls into a Medicare Advantage plan, that plan assumes all of the risks for that beneficiary. The plan administers their customer service, pays their claims, manages all of their care and the beneficiary must use the plan’s network of doctors and hospitals. In return, Medicare pays the plan a set amount of money to provide these services to the beneficiary.

Beneficiaries in a Medicare Advantage plan are still enrolled in the Medicare program, but their benefits are administered differently than Original Medicare.

MEDICARE ADVANTAGE- PART C ELIGIBILITY

To be eligible to join a Medicare Advantage Plan, beneficiaries must:

Live in the plan’s geographic service area
Have Medicare Part A and B and continue to pay their Part B premium
Agree to provide the necessary information to the plan
Agree to follow the plan’s rules
Belong to only one plan at a time

Individuals enrolled in an MA plan may not concurrently enroll in a PDP, except for individuals enrolled in an MSA plan or PFFS plan that does not offer Medicare prescription drug coverage.

Eligibility for MAPD does not exist for:

Incarcerated beneficiaries
Beneficiaries not lawfully present in the United States
Beneficiaries that live abroad
Any month prior to the month of notification of the entitlement determination when the entitlement determination for Part A and B is made retroactively.

Coverage:

Original Medicare	Medicare Advantage
Original Medicare covers most medically necessary services and supplies in hospitals, doctors’ offices, and other health care settings. Original Medicare doesn’t cover some benefits like eye exams, dental care, hearing benefits.	Plans must cover all of the medically necessary services that Original Medicare covers. Most plans offer extra benefits that Original Medicare docent cover- like vision, dental, hearing, and more.
Beneficiaries can join a separate drug plan (Part D) to get drug coverage.	Drug coverage (Part D) is included in most plans. In most types of Medicare Advantage plans, beneficiaries cannot join a separate Medicare drug plan.
In most cases, beneficiaries don’t have to get a service or supply approved ahead of time for Original Medicare to cover it.	In some cases, beneficiaries have to get a service or supply approved ahead of time for the plan to cover it.

Doctor and Hospital Choice:

Original Medicare	Medicare Advantage
Beneficiaries can go to any doctor or hospital that takes Medicare, anywhere in the U.S.	In many cases, beneficiaries will need to use doctors and other providers who are in the plan’s network and service area
In most cases, beneficiaries don’t need a referral to see a specialist.	Depending on the plan type a beneficiary may need to get a referral from their Primary Care Physician to see a specialist.
Original Medicare generally doesn’t cover care outside of the U.S.	Most Medicare Advantage plans cover a limited international coverage benefit.

Cost:

Original Medicare	Medicare Advantage
For Part A inpatient hospital stays, beneficiaries pay a per-occurrence deductible of $1,484 and potentially a copay for inpatient days after day 60. For Part B-covered services, beneficiaries usually pay 20% of the Medicare-approved amount after the annual deductible of $204 is met.	Out-of-pocket costs vary. Plans may have lower or no out-of-pocket costs for some services.
In most cases, beneficiaries pay a premium for Part B.	Beneficiaries pay the plan’s premium in addition to the monthly Part B premium. Most plans include drug coverage (Part D) Several health plans offer a $0 premium.
There is no yearly limit on what a beneficiary pays out of pocket unless they have a Medicare Supplement plan along with Original Medicare.	Most Medicare Advantage plans cover a limited international coverage benefit.
Beneficiaries can get a Medigap policy to help pay some of the out-of-pocket costs associated with the Original Medicare	Beneficiaries can’t buy a Medigap policy and a Medicare Advantage plan.

MEDICARE ADVANTAGE INITIAL COVERAGE ELECTION PERIOD (ICEP) – The ICEP is the period during which an individual newly eligible for MA may make an initial enrollment into a Medicare Advantage plan. This period begins three months immediately before the individual’s first entitlement to both Medicare Part A and Part B and ends the latter of:

The last day of the month preceding entitlement to both Part A and Part B, or:
The last day of the individuals Part B initial enrollment period.

The initial enrollment period for Part B is the seven (7) month period that begins 3 months before the month the individual meets the eligibility requirements for Part B and ends 3 months after the month of eligibility.

Once an ICEP enrollment request has been made and the enrollment takes effect, the ICEP election has been used.

Beneficiaries whose birthdays fall on the 1st of the month are eligible for Medicare Part A and B the month prior to their 65th birthday.

Individuals eligible for Medicare prior to age 65 will have another Initial Coverage Election Period upon attaining age 65.

MEDICARE ADVANTAGE ANNUAL ELECTION PERIOD (AEP)- runs from October 15th – December 7th of every year. The AEP is also referred to as the “Fall Open Enrollment” season and the “Annual Enrollment Period for Medicare Advantage and Medicare prescription drug coverage”.

During the AEP, MA or PDP eligible individuals may enroll in or disenroll from an MA or PDP plan.

The last enrollment request date, determined by the application date, will be the enrollment request that takes effect on January 1st of the following year.

INITIAL ENROLLMENT PERIOD FOR PART D (IEP)- the period during which an individual is first eligible to enroll in a Part D plan. In general, an individual is eligible to enroll in a Part D plan when he or she is entitled to Part A or is enrolled in Part B and permanently resides in the service area of the Part D plan.

During the IEP for Part D, individuals may make one part D enrollment choice, including enrollment into an MAPD plan.

Generally, individuals will have an IEP for Part D that s the same period as the Initial Enrollment Period for Medicare Part B.

Individuals eligible for Medicare prior to age 65 will have another Initial Election Period upon attaining age 65.

The ICEP and IEP for Part D occur together as one period when a newly Medicare Eligible individual has enrolled in BOTH parts A and B at first eligibility. Should an individual delay enrollment into Part B to a later time, the ICEP and IEP for Part D become separate with the ICEP changing to then occur as the 3 months immediately preceding entitlement to BOTH parts A and B.

If a Medicare entitlement determination is made retroactively, eligibility for Part D begins with the month in which the individual received notification of the retroactive entitlement decision. Therefore, the Part D IEP begins the month the individual receives the notice of the Medicare entitlement determination and continues for three additional months after the month the notice is provided. The effective date is generally the first day of the month after the organization receives a completed enrollment request.

In the MA context, the IEP for Part D applies only to MA-PD enrollment requests. Accordingly, when an applicant has both ICEP and IEP for Part D available to them, the plan must submit the application to CMS as an IEP for Part D election.

Medicare Advantage Open Enrollment Period (MA OEP)- is the time between January 1st and March 31 of every that allows a beneficiary already enrolled into a Medicare Advantage plan to make a one-time additional change.

During the MA OEP, MA plan enrollees may enroll in another MA plan or disenroll for their MA plan and return to Original Medicare.

Who can use the MA OEP:

MA OEP occurs:

Individuals enrolled in an MA plan

January 1 – March 31

New Medicare beneficiaries who are enrolled in an MA plan during their ICEP

The month of entitlement to Part A and Part B – the last day of the 3rd month of entitlement

Individuals enrolled in an MA plan may add or drop Part D coverage during the MA OEP.

Individuals enrolled in either MA-PD or MA-Only plans can switch to:

MA-PD with the same carrier or new carrier
MA-Only plan
Original Medicare with or without a stand-alone PDP

The effective date of an MA OEP election is the first of the month following receipt of the enrollment request.

The MA OEP does not provide an opportunity for an individual enrolled in Original Medicare to join a Medicare Advantage plan. This enrollment period does not apply to those enrolled into a PDP or a Medicare Savings Account.

GENERAL ENROLLMENT PERIOD- is the time between January 1st and March 31 of every year when a beneficiary can enroll into Medicare Part A and/or B for this first time. If a beneficiary enrolls during this time, their coverage will begin on July 1st.

Beneficiaries may enroll in a Medicare Advantage or Prescription drug plan during the period from April to June and their Medicare Advantage or Prescription drug plan will start on July 1st.

If a beneficiary does not enroll into a Medicare Advantage or Prescription Drug plan between April and June, they will need to wait until AEP to enroll into a Medicare Advantage or Prescription Drug plan, unless they qualify for another SEP.

Beneficiaries enrolling into Medicare during the General Enrollment Period will be subject to late enrollment penalties unless they qualify to have the penalties waived.