Medicare Advantage Plans

Medicare Advantage (Part C) plans are an alternative to Original Medicare, offered by private insurance companies. These plans bundle Part A (hospital), Part B (medical), and often Part D (prescription drugs) into a single plan.

Many Medicare Advantage plans also include:
✔️ Dental, Vision, and Hearing Benefits
✔️ Fitness Programs (SilverSneakers, Renew Active, etc.)
✔️ Over-the-Counter (OTC) Allowances
✔️ Transportation and Meal Delivery Services

Plan Types
1. HMO (Health Maintenance Organization): Requires a primary care provider (PCP) and referrals for specialists. You must stay in-network.
2. PPO (Preferred Provider Organization): Allows out-of-network providers but at a higher cost. No referrals needed.
3. PFFS (Private Fee-for-Service): No network restrictions, but providers must accept the plan’s terms.
4. SNP (Special Needs Plan): Tailored for chronic conditions or dual Medicare/Medicaid eligibility.

Eligibility and Enrollment
• Must have Medicare Part A & Part B.
• Must live within the plan’s service area.
• Can only enroll or switch plans during:
• Annual Enrollment Period (Oct 15 – Dec 7)
• Medicare Advantage Open Enrollment (Jan 1 – Mar 31)
• Special Enrollment Periods (SEPs) (if you qualify).

What’s the difference between Medicare Advantage and Original Medicare?

Medicare Advantage replaces Original Medicare (Part A & B) and is managed by private insurers. It often includes extra benefits but typically has provider networks (HMO, PPO, etc.). Original Medicare allows you to see any provider nationwide who accepts Medicare but does not include prescription drugs, dental, or vision unless added separately.

Do Medicare Advantage plans cover prescriptions?

Most Medicare Advantage Plans (MAPD) include drug coverage. If your plan does not include Part D, you cannot enroll in a separate drug plan unless you have a Medical Savings Account (MSA) or PFFS plan without drug coverage.

Can I switch from Medicare Advantage to Original Medicare?

Yes, but only during:
• Medicare Advantage Open Enrollment (Jan 1 – Mar 31).
• Annual Enrollment (Oct 15 – Dec 7).
• Special Enrollment Periods (if eligible).
If you switch back, you may need Medigap (Medicare Supplement) coverage to cover out-of-pocket costs.

What happens if I move to another state?

You must notify your plan. If your plan does not operate in your new state, you qualify for a Special Enrollment Period to choose a new plan.

Medicare Supplement Plans

Medigap plans work alongside Original Medicare to cover out-of-pocket costs like deductibles, copayments, and coinsurance.

These plans do not include prescription drugs, dental, or vision, but they offer nationwide provider access—unlike Medicare Advantage.

Coverage Details
• Plans A, B, C, D, F, G, K, L, M, and N cover various costs.
• Plan G is the most popular, covering everything except the Part B deductible ($240 in 2024).

How Medigap Complements Original Medicare

✔️ Covers out-of-pocket Medicare costs
✔️ No network restrictions—see any doctor nationwide
✔️ Guaranteed renewable (cannot be canceled due to health changes)

How is Medigap different from Medicare Advantage?

• Medigap works with Original Medicare to fill coverage gaps.
• Medicare Advantage replaces Original Medicare with a private plan.
Medigap allows unrestricted provider access, while Medicare Advantage often uses networks (HMO, PPO).

When can I enroll in Medigap?

The best time is during your Medigap Open Enrollment Period (OEP):
• Starts the first month you have Medicare Part B and are 65+.
• No medical underwriting required during this period.
Outside of OEP, medical underwriting applies, meaning you could be denied coverage or charged higher rates.

Can I switch Medigap plans later?

Yes, but medical underwriting applies unless you have guaranteed issue rights (e.g., losing employer coverage).

Medicare Prescription Drug Plans

Part D plans help cover prescription medication costs.

How to Choose the Right Plan

✔️ Check if your medications are covered (formulary list)
✔️ Compare premium, deductible, and copay costs
✔️ Ensure your preferred pharmacy is in-network

What happens if I don’t enroll in a Part D plan when first eligible?

You will face a late enrollment penalty if you go 63+ days without creditable drug coverage. Penalty = 1% of the national base premium ($34.70 in 2024) × the number of months without coverage.

What if my medication isn’t covered?

• Request a formulary exception from your plan.
• Check alternative covered medications with your doctor.
• Switch plans during Annual Enrollment (Oct 15 – Dec 7).

Can I switch Medigap plans later?

Yes, but medical underwriting applies unless you have guaranteed issue rights (e.g., losing employer coverage).