What You Need to Know About Medicare Advantage 

Who can join a Medicare Advantage plan?

To join a Medicare Advantage plan you must:  

  • Have Part A and Part B.  
  • Live in the plan’s service area.  
  • Be a U.S. citizen or lawfully present in the U.S.  

When can you join a Medicare Advantage plan?

You can join a Medicare Advantage plan at certain times even if you have a pre-existing condition.  

You can join or leave a Medicare Advantage Plan only at certain times during the year, such as the time surrounding your 65th birthday, when you move to a different county, when you lose your other health care coverage, or other special circumstances.  

Each year, Medicare Advantage Plans can choose to leave Medicare or make changes in coverage, costs, service area, and more. If the plan decides to stop participating in Medicare, you’ll have to join another Medicare Advantage Plan or return to Original Medicare. Medicare Advantage Plans must follow certain rules when giving you information about how to join their plan for more information about these rules and how to protect your personal information.  

What do I need to know if I have a Medicare Advantage plan?

If you’re in a Medicare Advantage plan, review the “Annual Notice of Change” and “Evidence of Coverage” from your plan each year:  

  1. Annual Notice of Change: Includes any changes in coverage, costs, and more that will be effective starting in January. Your plan will send you a printed copy by September 30.  
  1. Evidence of Coverage: Gives you details about what the plan covers, how much you pay, and more. Your plan will send you a notice (or printed copy) by October 15, which will include information on how to access the Evidence of Coverage electronically or request a printed copy.  

If you don’t get these important documents, contact your plan.  

Are you eligible for Medicare Advantage? 

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My Provider Doesn’t Accept Medicare 

Certain doctors and other health care providers who don’t want to work with the Medicare program may “opt out” of Medicare. Medicare doesn’t pay for any covered items or services you get from an opt out doctor or other provider, except in the case of an emergency or urgent need. If you still want to see an opt out provider, you and your provider can set up payment terms that you both agree to through a private contract.  

What does assignment mean?

Assignment means that your doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services.  

If your doctor, provider, or supplier accepts assignment:  

  • Your out-of-pocket costs may be less.  
  • They agree to charge you only the Medicare deductible and coinsurance amount and usually wait for Medicare to pay its share before asking you to pay your share.  
  • They have to submit your claim directly to Medicare and can’t charge you for submitting the claim.  

Some providers haven’t agreed and aren’t required by law to accept assignment for all Medicare-covered services, but they can still choose to accept assignment for individual services. The providers who haven’t agreed to accept assignment for all services are called “non-participating.” You might have to pay more for their services if they don’t accept assignment for the care they provide to you. Here’s what happens if your doctor, provider, or supplier doesn’t accept assignment: 

  • You might have to pay the entire charge at the time of service. Your doctor, provider, or supplier is supposed to submit a claim to Medicare for any Medicare-covered services they provide to you.  
  • They can charge you more than the Medicare-approved amount. In many cases, the charge can’t be more than an amount called “the limiting charge.”  

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Medicare Advantage Plans Benefits 

Most Medicare Advantage Plans offer coverage for things Original Medicare doesn’t cover such as: fitness programs (like gym memberships or discounts) and some vision, hearing, and dental services. Plans can also choose to cover even more benefits. For example, some plans may offer coverage for services like transportation to doctor visits, over-the-counter drugs, and services that promote your health and wellness.  

Plans can also tailor their benefit packages to offer additional benefits to certain chronically-ill enrollees. These packages will provide benefits customized to treat specific conditions. Check with the plan before you enroll to see what benefits it offers, if you might qualify, and if there are any limitations 

Medicare Advantage Plans must follow Medicare’s rules

Medicare pays a fixed amount for your coverage each 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 doctors, facilities, or suppliers that belong to the plan’s network for non-emergency or non-urgent care). These rules can change each year. The plan must notify you about any changes before the start of the next enrollment year.  

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If I Didn’t Get Enrolled in Medicare automatically, when can I enroll? 

If you didn’t get automatically enrolled in premium-free Part A (for example, because you’re still working and not yet getting Social Security or Railroad Retirement Board (RRB) benefits), you can sign up for premium-free Part A (if you’re eligible) any time during or after your Initial Enrollment Period begins. 

f you’re eligible for premium-free Part A, you can enroll in Part A any time after you’re first eligible for Medicare. Your Part A coverage will go back (retroactively) 6 months from when you enroll, but no earlier than the first month you’re eligible for Medicare. You can only sign up for Part B during the periods listed below. 

Remember, in most cases, if you don’t enroll in Part A (if you have to buy it) and Part B when you’re first eligible, your enrollment may be delayed and you may have to pay a late enrollment penalty. 

Are you eligible for Medicare Enrollment? 

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Medicare Enrollment Periods

You can only enroll in Part B (and/or Part A if you have to buy it) during these enrollment periods.

Initial Enrollment Period

You can first sign up for Part A and/or Part B during the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.

If you enroll in Part A and/or Part B during the first 3 months of your Initial Enrollment Period, in most cases, your coverage begins the first day of your birthday month. However, if your birthday is on the first day of the month, your coverage will start the first day of the prior month.

If you enroll in and are paying for Part A and/or Part B the month you turn 65 or during the last 3 months of your Initial Enrollment Period, the start date for your Part B coverage will be delayed.

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Special Enrollment Period (SEP)

After your Initial Enrollment Period is over, you may have a chance to enroll in Medicare during a Special Enrollment Period. If you didn’t sign up for Part B (or Part A if you have to buy it) when you were first eligible because you have group health plan coverage based on current employment (your own, a spouse’s, or a family member’s—if you have a disability), you can enroll in Part A and/or Part B:

Anytime you’re still covered by the group health planDuring the 8-month period that begins the month after the employment ends or the coverage ends, whichever happens first

Usually, you don’t pay a late enrollment penalty if you sign up during a Special Enrollment Period. This period doesn’t apply if you’re eligible for Medicare based on End-Stage Renal Disease (ESRD), or you’re still in your Initial Enrollment Period.

Note: If you have a disability, and the group health plan coverage is based on a family member’s current employment (other than a spouse), the employer offering the group health plan must have 100 or more employees for you to get a Special Enrollment Period.

See If You’re Eligible for SEP

General Enrollment Period

If you have to pay for Part A but don’t sign up for it and/or don’t sign up for Part B (for which you must pay premiums) during your Initial Enrollment Period, and you don’t qualify for a Special Enrollment Period, you can sign up during the General Enrollment Period between January 1–March 31 each year. Your coverage won’t start until July 1 of that year, and you may have to pay a higher Part A and/or Part B premium for late enrollment.

Are you eligible for Medicare Enrollment?

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