A person can switch their Medicare Advantage plan at specific enrollment periods during the year. Special circumstances may allow changes outside those enrollment periods.
When a person enrolls in a Medicare Advantage plan, they do not have to stay with that plan for the rest of their life. A person may choose to switch plans if they are unhappy with the coverage or if specific circumstances in their life change that may make a different plan more suitable.
This article looks at Advantage plans and discusses how a person can switch between plans, and when to switch. It also discusses eligibility and costs.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare Advantage is an alternative to original Medicare. According to the Kaiser Family Foundation (KFF), 34% of people enrolled in Medicare have Advantage plans.
Original Medicare is federally managed health insurance for adults aged 65 and older and younger adults with disabilities. It includes Part A and Part B, which together cover hospital inpatient care and outpatient services. Benefits are the same for any individual who enrolls, regardless of preexisting health conditions.
Medicare Advantage plans are offered by private insurance companies. The federal government sets the guidelines and rules, and Advantage plans must cover the same services as original Medicare.
However, Advantage plans may also offer additional health coverage, such as prescription drug coverage.
Types of Advantage plans
There are several types of Advantage plans. Four of the most common ones include:
- Health maintenance organizations (HMO)plans provide insurance coverage from doctors and hospitals within a specific network. A person chooses their primary care doctor and may need a referral to see a specialist.
- Preferred provider organizations (PPO) plans offer a person the choice of selecting a doctor out of their network, although the cost may increase. A person does not need a referral to see a specialist.
- Private fee for service (PFFS) plans do not make a person choose a primary care doctor, nor does a person need a referral to see a specialist.
- Special needs plan (SNP) enrollment is limited to a person with specific diseases or conditions.
A person can use this online tool to find an Advantage plan in their area.
To switch a Medicare Advantage plan, a person can compare the different plans online and choose one that suits them. A person can also call 800-MEDICARE (800-633-4227) to find a plan in their area.
A person can then enroll in the new plan during one of the available enrollment periods. When coverage from the new plan begins, a person is automatically disenrolled from their previous plan.
A person can switch plans during the initial enrollment period (IEP), the Advantage open enrollment period (OEP), the fall OEP, or in special circumstances.
The three enrollment periods when a person can switch plans are shown below. They are followed by details about the special circumstances period.
Initial enrollment period (OEP)
A person can switch to a Medicare Advantage plan during their OEP.
If a person qualifies because they are turning 65, the initial enrollment begins three months before the month they become 65, includes the birth month, and ends three months later.
If a person is qualifying for Medicare based on a disability, and gets Social Security disability insurance or Railroad Board benefits, the enrollment period is different. In this case, the period is 3 months before a person has been getting benefits for 25 months, includes that month, and continues for another 3 months.
A person can switch Medicare Advantage plans during the yearly Medicare Advantage open enrollment period, which is from January 1 to March 31. The change in plans takes effect on the first day of the month following the month a person enrolls. For instance, if an individual switched plans in January, the new plan coverage starts February 1.
During the Fall open enrollment period from October 15 to December 7, a person can choose to switch Medicare Advantage plans. Changes take effect on January 1.
A person can choose to:
- switch from one Medicare Advantage plan to another
- switch to a new Medicare Advantage plan that does not include prescription drug coverage
- switch from Medicare Advantage to original Medicare, either with or without a Part D drug plan
A person may also switch Medicare Advantage plans in specific cases when certain life circumstances occur, as shown below.
Special enrollment period (SEP)
A person may qualify for a special enrollment period (SEP) because of various circumstances, such as:
- moving back to the United States from out of the country
- loss of other health insurance
- release from jail
- moving in or out of a skilled nursing facility
The exact rules for changes allowed during SEPs may vary, and a person can check the details with their Medicare Advantage plan provider.
Anyone who is eligible for original Medicare is also eligible for a Medicare Advantage plan.
A person is eligible for original Medicare if they are a U.S. citizen or has held permanent resident status for a minimum of 5 years, and they also meet one or more of the requirements below:
- is 65 years or older
- has a disability
- has end stage renal disease
- has amyotrophic lateral sclerosis
To qualify for an Advantage plan, a person must have enrolled in original Medicare or meet eligibility requirements, and live in the insurance plan’s service area.
Costs of Medicare Advantage plans vary and depend on several factors, including where a person lives, the coverage provided by individual plan providers, and additional benefits offered by some plans.
Medicare Advantage plans may incur the cost of a monthly premium, deductible, and extra benefits that original Medicare does not cover, such as dental care.
Most Advantage plans also have out-of-pocket costs that a person must meet before health coverage begins. Again the amounts may vary, and a person can check the details with the plan provider, or use this online comparison tool.
According to the Kaiser Family Foundation (KFF), the average Advantage plan premium in 2020 was $25.
A person can switch Medicare Advantage plans during specific enrollment periods and sometimes in special enrollment periods because there are certain circumstances, such as moving to a new location, or losing other health insurance coverage.