An introduction to eligibility, coverage, and Medicare Advantage
Whether you’re about to become eligible for Medicare or need a change to your policy, it’s helpful to know the basics to make informed decisions about your future. With over 62 million Americans enrolled, Medicare is the largest health insurance program in the U.S., intended for people 65 years and older or living with a qualifying disability or End-Stage Renal Disease.
Medicare Advantage provides “all-in-one” Medicare coverage. Also known as Part C, MA combines the essential components of Part A (hospital insurance) and Part B (medical and outpatient insurance), adding a few other types of insurance to provide full coverage for nearly 40% of all Medicare beneficiaries.
To learn more about enrollment and eligibility into Medicare Advantage, refer to these frequently asked questions (FAQs).
The ABC’s of Medicare
Medicare is comprised of four different parts: A, B, C & D. Parts A and B are sometimes referred to as Original Medicare and are managed by the Federal Government. Parts C and D are offered by private insurance companies that contract directly with Medicare.
- inpatient care in hospitals
- skilled nursing facility care
- hospice care
- home health care
- Services from doctors and other health care providers
- Outpatient care
- Home health care
- Durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment)
- Many preventive services (like screenings, shots or vaccines, and yearly “Wellness” visits)
Also known as Medicare Advantage, Part C is an alternative to traditional Medicare coverage. Coverage normally includes all of Parts A and B, a prescription drug plan (Part D), and, depending on your choice of a Medicare Advantage plan, other possible benefits such as Dental, Vision, and Hearing.
Part C is administered by Medicare-approved private insurance companies that collect your Medicare payment from the federal government.
- the cost of prescription drugs (including many recommended shots or vaccines).
You join a Medicare drug plan in addition to Original Medicare, or you get it by joining a Medicare Advantage Plan with drug coverage. Plans that offer Medicare drug coverage are run by private insurance companies that follow rules set by Medicare.
Medicare Advantage FAQs
Answers to commonly asked questions concerning Medicare Advantage
With Medicare Advantage, you receive the same coverage you would get with Traditional Medicare (Parts A and B) alongside other types of coverage, like vision, hearing, and dental. If you have a chronic illness, you can even choose a Medicare Advantage plan created specifically with your illness in mind, making it easier to receive ongoing treatments.
By law, Medicare Advantage will always cover the same services as Traditional Medicare, with the exception of hospice care. That means Medicare Advantage includes hospital care, medical care, outpatient care, prescription drug, vision, dental, and hearing insurance. Depending on the provider you choose, it can also come with additional benefits, like gym memberships and discounts, reimbursements for transportation to doctors’ appointments, and coverage for over-the-counter drugs.
The most common Medicare Advantage plans are Health Maintenance Organization (HMO) plans, Preferred Provider Organization (PPO) plans, Private Fee-for-Service (PFFS) plans, and Special Needs Plans (SNPs). Less common are HMO Point-of-Service (HMOPOS) plans and Medical Savings Account (MSA) plans.
It depends on your eligibility. If you’re eligible based on age, the earliest you can enroll in Medicare Advantage is 3 months before you turn 65, which marks the start of your initial enrollment period. Your initial enrollment period lasts for 7 months, after which you may incur late fees or experience wait times while enrolling.
Medicare’s annual election period (or annual enrollment period) is when those who aren’t enrolled in Medicare can join, and anyone already enrolled can make changes to their coverage. It lasts from October 15 to December 7 each year.
If you’re already enrolled in Medicare Advantage, open enrollment is another opportunity to make a one-time change to your plan. It lasts from January 1 to March 31 each year.
A special enrollment period is when you can sign up for Medicare Advantage after your initial enrollment period or outside of the annual election period due to certain qualifying life events. These include losing health coverage, moving, getting married, having a baby, or adopting a child, or being dual-eligible for Medicaid or Low-Income Subsidies.
Qualifying life events are occasions that trigger special enrollment periods, allowing you to sign up for Medicare outside of the annual election period. They include losing health coverage, moving, getting married, having a baby, or adopting a child. For a full list, visit medicare.gov.
Most Medicare Advantage plans cover dental, hearing, and vision, but it’s important to check with your plan provider as coverage varies between plans.
Yes, you will most likely be able to keep your doctor under Medicare Advantage. If this is important to you, you can choose a plan that has your doctor in network or provides out-of-network coverage.
Most Medicare Advantage plans include prescription drug coverage and will allow you to keep your prescriptions. Be sure to check with the plan provider before enrolling.
With Medicare Advantage, you can see any doctor in your network, and sometimes doctors out of network, depending on your plan. It’s best to check with your plan provider before scheduling an appointment with someone out of network.
Under Medicare Advantage, you usually continue to pay a premium for Part B (medical insurance) coverage, and a second premium for additional coverage. In 2020, the standard Part B premium was $144.60 per year. Other premiums, deductibles, and service charges are determined by the plan. Premiums for MA plans start as low as $0.
A deductible is the amount of money you would need to pay for a service or drug before your insurance carrier starts paying.
Copays are fixed fees you have to pay for certain Medicare Advantage services, like doctor’s visits and prescription refills.
Coinsurance is the amount, often a percentage, you have to pay of the cost of a service after the deductible has been paid.