Key Takeaways
Medicare Advantage Plans can only be purchased or changed during specific enrollment periods.
There are three types of Enrollment Periods;
Initial Enrollment Period (when you first start Medicare),
Annual Enrollment Periods (these repeat at the same time every year)
Special Enrollment Periods (the result of losing health insurance coverage)
What are Medicare Advantage Plans?
A Medicare Advantage plan, also known as Medicare Part C, is a health insurance plan offered by private companies approved by Medicare. A Medicare Advantage plan replaces Original Medicare with a privatized version operated by a for profit insurance company.
A Medicare Advantage plan is required to provide benefits from the same benefit categories as Original Medicare, but not the same benefits or costs.
Medicare Advantage plans are annual plans. This means that every Advantage plan ends on December 31st of each year. The new annual plan can have the same name, but different benefits, costs and network.
What are Medicare Advantage Plan Enrollment Periods?
A Medicare beneficiary can only purchase, cancel or switch Medicare Advantage plans during specific periods of time during the year. We call these periods of time enrollment periods.
Initial Enrollment Period
A Medicare beneficiaries Initial Enrollment Period occurs when they are age 65 or over, and enrolled in both Medicare Part A and Medicare Part B. For most people, this Initial enrollment Period is a seven month window around their 65th birthday month.
People who become eligible for Medicare before age 65 receive two Initial Enrollment Periods. One on the 25th month of receiving Social Security disability benefits when they begin Medicare coverage, and then again when they turn age 65.
When you first apply for Medicare you receive Original Medicare Part A (inpatient) and Part B (outpatient) coverage.
Annual Enrollment Period (AEP)
The Annual Election Period takes place from October 15th to December 7th
annually. During this period, beneficiaries can enroll in or switch Medicare Advantage Plans or Part D prescription drug plan. They may also disenroll from a Medicare Advantage plan . Changes made during AEP become effective on January 1st of the following year. This enrollment period is sometimes referred to as a Medicare Open Enrollment Period.
Medicare Open Enrollment Period (OEP)
Medicare Advantage Open Enrollment Period occurs from January 1st to March 31st each year. During Medicare Advantage Open Enrollment, individuals who already have a Medicare Advantage plan can switch Medicare plans or return to Original Medicare. Changes made during the Medicare Advantage Open Enrollment period become effective on the first day of the month following the plan change.
The objective is to find the right health coverage for your needs. If you need to switch plans, Medicare has made that easy.
Special Enrollment period (SEP)
A Special Enrollment Period occurs when a Medicare beneficiary loses Medicare or health insurance coverage through no fault of their own. They could be retiring and losing group coverage, moving out of the plan’s service area or even if their Advantage plan goes out of business. With an SEP, there is a brief period of time (typically 63-days) to choose a new Medicare plan.
Moving out of your current Plan’s service area provides a Special Enrollment where you can switch back to Original Medicare and apply for a Medigap policy or get a new Medicare Advantage Plan based on your new address.
Dual-eligibility and state-specific programs
Individuals who are eligible for both Medicare and Medicaid (dual-eligible) often have more flexibility to change plans due to state-specific Medicaid rules. State-sponsored programs and initiatives can impact plan change options, offering additional opportunities for adjustments. Dual eligible beneficiaries have a different open enrollment period than others on Medicare.
On top of that, certain states may have their own assistance programs designed to aid beneficiaries in understanding and navigating plan changes and new coverage. Some individuals may be able to change coverage on a quarterly basis.
Why Would I Need to Change Medicare Advantage Plans?
We advise our clients to re-shop their Medicare Advantage Plan every year for two reasons. First, the benefits, costs or plan network can change every calendar year. If you do not re-shop your plan you can find out too late that your doctor no longer accepts that insurance, or that your prices for prescription drugs are much higher.
Second is that your own needs can change. Your medications can change, your may need to see a specialist and so on. It cost nothing to re-shop Medicare plans to find the one best suited for your needs and budget.
There are approximately 4,000 different Medicare Advantage Plans in the U.S., each with its own benefit cost structure and network. They do not all have the same coverage. It’s unlikely the right Medicare Advantage Plan for you will be the same plan year in and year out.
How Do I Evaluate a Different Medicare Advantage Plan?
When assessing Medicare Advantage plans, you’ll need to consider plan types and compare coverage, benefits, network and costs. Most importantly, you will want to know what the annual Maximum out-of-pocket cost limit on your expenses may be.
Types of MA plans
Medicare Advantage plans come in various forms, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, and Special Needs Plans (SNPs). Each type has distinct features and limitations, impacting factors like provider choice and referrals.
Step-by-Step Guide to Advantage Plan Shopping
Every Medicare insurance company that offers Advantage plans offers multiple plans. You can call each insurance company, ask for information on each of their plans and spend a few weekends comparing benefits. Or, simply work with an independent Medicare broker who has access to all that information packaged in state of the art software to help you go from start to finish in less than an hour.
It’s important that your insurance broker know which enrollment period you qualify for, so they can show you all the Medicare plans available to you and when you need to make a decision.
For example: a Special Enrollment Period may only last 63-days, but allow
you to change Medicare Advantage plans or select from guarantee issue Medicare supplements. A Special Enrollment Period ends when you apply for a Medicare plan. Conversely, during the Annual Open Enrollment period you can change Advantage plans and change your mind as often as which until the enrollment period ends.
Step One
The first step is to provide your broker with your list of doctors and your current medications. When sorting through the plans available to you, we first must make certain your doctors are in-network and your prescription drugs are covered at a reasonable cost. The drug plan portion of coverage is important.
Step Two
By law, before your insurance broker can help you, they need a signed SCOPE of Appointment form. This form is an anti bait-and-switch form. It list out the subjects you want to cover in the meeting. For example Medicare Advantage Plans, Part D plans and Medicare supplements. Nothing outside of the SCOPE is allowed to be discussed for 48-hours after the meeting. This stops unscrupulous sales agents from trying to sell life insurance during a Medicare meeting.
Independent brokers are required to keep the SCOPE on file for ten years.
Step Three
With the first two steps out of the way, your broker should be able to show you all the plans in which your doctors are in network and your drugs are covered with an adequate drug plan. Next is to sort by annual maximum-out-of-pocket. This is the most money you will spend in any one calendar year as long as you follow the insurance company rules.
Step Four
Decide if you prefer an HMO or a PPO. From there, also sort by monthly premium, if any.
With the low premium HMO or PPO in front of you, take a look for any
annual deductibles and office visit copays. After this step, there should be just a few plans that make the cut.
Step Five
Of the plans that are left now is the time to review their extra benefits. This may include dental benefits, gym membership, meal plans and so on. You know all the plans left have the health coverage you want, at a reasonable price. Use the extra benefits to find the plan you want.
Apply for the Medicare Advantage Plan
When changing Medicare Advantage Plans, when you apply for a new plan Medicare will cancel your current Medicare Advantage plan. You do not need to call or write them to let them know you are change Medicare advantage plans.
Contact an independent insurance broker like Medigap Seminars, for a free and friendly consultation on all things Medicare.
Matthew Claassen
Matthew Claassen, CMT and CEO of Medigap Seminars Insurance Agency. Medigap Seminars is an award winning premier national Medicare Insurance Brokerage, ranked among the top in the U.S.A. Matthew is considered a leading national expert on Medicare and Social Security. Mr. Claassen is a distinguished member of the Forbes Business council, an invitation only organization of business leaders and entrepreneurs. He and his team have received awards from many of the countries largest insurance companies including Mutual of Omaha, Aetna, Humana, Cigna, United American, United Healthcare and others. His videos have become the most popular Medicare educational videos on YouTube with millions of views. As a financial analyst Matthew lead a team of researchers to win the 2009 Best Equity Research & Strategy Award from The Technical analysis magazine.
