Medicare has two primary parts to it. Medicare Part A and Part B. To simplify things: Think of Part A as Hospital and Part B as almost everything outside of the hospital and pharmacy. What about Part C and Part D? We’ll cover those parts soon.

Medicare Part A covers five primary areas: Hospital Care, Skilled Nursing Facility Care, Nursing Home Care, Hospice, and Home Health Services.

For most people, Medicare Part A is free. However, if you or your spouse have not earned enough "quarters" to qualify for Premium-Free Medicare (40), then there will be a monthly fee for Medicare Part A.

No, it is not. First, there is a deductible of $1,700 (in 2023) for inpatient hospital care. Then a copay of $400 daily for days 61-90, and a copay of $800 daily for Medicare’s 60 Reserve Days.

Questions and answers on this Medicare Information Site were prepared and written by Scott Shafran, owner of StartMedicareRight.com. Scott has been helping people with Medicare and Medicare-related health insurance since 2010.

Skilled Nursing Facility Care is the second major area of coverage under Medicare Part A. If you’ve been an inpatient in a hospital for at least 3 days, then go into a Skilled Nursing Facility (SNF), the SNF will be covered by Medicare for the first 20 days with no out-of-pocket expense for you. But if you are in the facility beyond 20 days, you’ll begin to incur daily charges of up to $200 per day (2023).

WHAT DOES MEDICARE PART B COVER?

IS ALL OF THE PREVENTATIVE CARE, COVERED UNDER PART B, FREE FOR ME IF I JUST HAVE MEDICARE?

WHAT ARE SOME OF THE MEDICAL SERVICES COVERED UNDER MEDICARE PART B?

WHAT MEDICATION IS COVERED UNDER MEDICARE PART B?

Medicare Part B and Drugs: Most medication is covered under a different part of Medicare – Medicare Part D. But there are some drugs that are covered under Medicare Part B, and it’s extremely important to know which section of your insurance is covering your drugs.

Drugs with Medical Equipment. Let’s use Insulin as an example. Insulin is normally covered under a Medicare Part D plan when taken via needle. It can be extremely expensive, especially during the coverage gap (donut hole). However, insulin is covered under Medicare Part B when taken through the use of an insulin pump. Knowing this is helpful because it will be something to consider when you choose your secondary insurance. Another example is medicine used in a Nebulizer, which is often covered under Medicare Part B as it is medication used in conjunction with Part B covered medical equipment.

Drugs administered by a doctor, like Chemotherapy.

Specialty drugs like immunosuppressive drugs – after a Medicare-covered organ transplant, Medicare covers transplant drug therapy – special circumstances apply

HOW MUCH DOES MEDICARE PART B COST?

Medicare Part B has a premium attached to it which most people are required to pay. It’s important to remember that the Part B premium is what you pay for original Medicare coverage, regardless of whether you enroll in a Medicare Supplement Plan (Medigap Plan) or a Medicare Advantage Plan. Think of the price you pay for Medicare Part B as the price you pay for the foundation of a home. You pay for it before you pay for anything else that might be extra.

In 2023, the standard premium for Medicare Part B is $164.90/mo for most people on Medicare. Individuals earning over $97,000, and couples earning over $194,000, will pay more for their Part B (This is called the Income Related Monthly Adjustment Amount). The earnings are based on tax returns from two years prior (i.e., 2023 premium is based on tax returns from tax year 2021; 2024 is based on 2022, etc.).

Individuals:
Income Under $97,000 in 2021? You’ll pay $164.90

Income Between $97,000 and $123,000? You’ll pay $230.80

Income Between $123,000 and $153,000? You’ll pay $329.70

Income Between $153,000 and $183,000? You’ll pay $428.60

Income Between $183,000 and $500,000? You’ll pay $527.50

Income over $500,000? You’ll pay $560.50

Married Filing Jointly:
Income Under $194,000 in 2021? You’ll pay $164.90

Income Between $194,000 and $246,000? You’ll pay $230.80

Income Between $246,000 and $306,000? You’ll pay $329.70

Income Between $306,000 and $366,000? You’ll pay $428.60

Income Between $366,000 and $750,000? You’ll pay $527.50

Income over $750,000? You’ll pay $560.50

Married Filing Separately:
Income Under $97,000 in 2021? You’ll pay $164.90

Income Between $97,000 and $403,000? You’ll pay $527.50

Income over $403,000? You’ll pay $560.50

There is help available for those who struggle to afford the premium of $164.90 per month. State Medicare Savings Programs (MSP) can help. For further assistance, you can see the full description of the Medicare Savings Programs by visiting Medicare’s site - click here.

The “short and simple” answer is that you’ll pay your Part B deductible ($226 in 2023) and 20% coinsurance.

The Part B deductible tends to change every year. In 2015, it was $147, in 2016 it was $166. In 2017 it jumped to $183, but it stayed at $183 for 2018. It was $185 in 2019, $198 in 2020, $203 in 2021, and $233 in 2022. In 2023, the Part B deductible will go down to $226. Most people agree that the increases in the Part B deductible have been modest.

Maybe.

HOW CAN I SIGN UP FOR MEDICARE?

See video (above). The easiest way to sign up for Medicare is on the Social Security website. While it would be logical to be able to sign up for Medicare on the Medicare website - this is not the case :)

HOW EARLY CAN I SIGN UP FOR MEDICARE A & B?

HOW DO I PAY FOR MEDICARE?

Questions and answers on this Medicare Information Site were prepared and written by Scott Shafran, owner of StartMedicareRight.com. Scott has been helping people with Medicare and Medicare-related health insurance since 2010.

DOES MEDICARE PAY FOR PRESCRIPTION MEDICATION?

A very, very common questions we get is this: “I’ve heard about Medicare Part D - that it covers prescriptions. What is Medicare’s prescription coverage like?”

Medicare Part D is only offered by private insurance companies. Medicare itself does not cover medications obtained at the pharmacy. However, Medicare does set the standards and the requirements for the private insurance companies.

This means that when a private insurance company wants to offer prescription coverage to people who are on Medicare, that they have to follow Medicare’s requirements in order to do so and in order to be a Medicare Part D plan. Therefore, there is a lot of variety. Medicare sets the pattern and requirements, and the private insurance companies create different plans within those requirements.

So, the answer is no, Medicare does not cover prescription medications. However, Medicare has created a program (called Medicare Part D) that allows private insurance companies to cover prescription medications.

WHAT IS A MEDICARE SUPPLEMENT PLAN? (ALSO CALLED: MEDIGAP)

A Medicare Supplement (also called “Medigap”) is secondary insurance - it fills in the "gaps" of Medicare. Once you see a doctor or receive a medical bill, the supplement can pay a portion (or all) of the bill after Medicare pays it’s portion of the bill.

For example, Medicare Part A has a $1,600 deductible (2023) at the hospital. Most Medicare Supplements will pay that $1,600 deductible for you.

The Medicare Supplements can also assist on paying the remaining 20% of charges (after Medicare Part B pays 80% of the bill).

There are several different Medicare Supplement plans, and each Medicare Supplement plan works a little bit differently.

There are 12 Medicare Supplement plans available currently.

WHAT MEDICARE SUPPLEMENT PLANS ARE POPULAR?

The three most popular Medicare Supplement plans are Plans F, G, and N. Let’s take a look at some of the most recent available enrollment statistics:

Please note: These statistics are approximate and have a slight margin of error.

Plan F = 54.63%

Plan G = 10.03%

Plan N = 9.06%

Plan C = 7.13%

Plan J, which has been discontinued, used to be very popular before they modernized the Medicare Supplements in 2010. It still holds about 3.81% of the market share, coming in as the 5th most popular plan.

All other plans account for less than 3% of the market share.

*Primary Sources: Mark Farrah Associates and Medicaresupp.org

These three plans are popular for a variety of reasons.

Plan F is popular because people who sign up for Plan F like knowing that they have complete medical coverage, as Plan F covers the Part A and Part B copays and deductibles.

Plan G is popular because it’s similar to Plan F, but normally less expensive monthly and the only out-of-pocket cost difference is the small Medicare Part B deductible.

Plan N is even cheaper still, but it has 2 extra copays ($20 at the doctor, and $50 at the ER). Plan N also excludes coverage for excess charges. People like Plan N because it still gives full Part A coverage, and the smaller things that aren’t covered are manageable for them.

WILL PLAN F CONTINUE TO BE THE MOST POPULAR PLAN INDEFINITELY?

HOW MUCH DO MEDICARE SUPPLEMENTS COST?

The price of a Medicare Supplement Plan is dependent on many factors. Specifically, the price is based on Six Factors: (a) Location (b) Gender, (c) Tobacco Usage, (d) Health, (e) Discount Availability, and (f) Age. Let’s take a look at these six factors.

A very general pricing guide for a Medicare Supplement policy would be that you should expect to pay at least $85 for a Plan N, $105 for a Plan G, and $130 for a Plan F if you are a female and new to Medicare at age 65. You should expect to pay about $10-15 more if you are a male and new to Medicare at age 65. To be very clear: you will likely pay more - as these are some of the lowest prices that I’ve observed over the years. As you can see, however, the prices will vary (sometimes drastically) based on the above 6 factors of Location, Gender, Tobacco Usage, Health, Discount Availability, and Age.
 

Location - Your price will be determined partly by your location.
Zip Code: Most Medicare Supplement prices are zip-code specific, but this is up to the carrier to decide. For example, one carrier may group regions of a state into sections based on the first three numbers in a zip code (called the SCF code) and price their Medicare Supplements accordingly.
County: Other Medicare supplement companies choose to price their plans based on which county you are in.
Statewide Rates: Finally, some carriers will charge the same price throughout the state that you live in.
 

Gender - Your price is often determined by your gender. There are some carriers which have “unisex rates” in that they do not have different male/female rates - but most carriers charge higher rates for males, and lower rates for females.
 

Tobacco Usage - Most insurance companies will want to know whether or not you’ve used tobacco within the past 12 months. Based on a “yes” answer to tobacco usage, many companies will increase the premium that you pay. But, there are some exceptions to this rule of thumb. (A) The main exception is when you are new to Medicare and in your Medicare Open Enrollment. During your open enrollment, in many states, some of the insurance companies “waive” the tobacco-rate increase. If you are a tobacco user, it would be worthwhile for you to find a carrier that will give you non-tobacco rates. (B) The second exception to this is that some insurance companies do not charge premiums based on tobacco usage. While this is a little bit rarer, it is a factor that can be helpful if you are not in your open enrollment.
 

Health - If you are in your open enrollment, then you don’t need to worry about your health status affecting your rates. During your open enrollment, a carrier can not ask you health questions, and they cannot base your premium on pre-existing conditions or exclude anything from coverage. If you are not in your open enrollment, and you are looking for a Medicare Supplement plan, then you’ll need to answer health questions and your answers may affect your rate. Most insurance carriers will “tier” their health questions. If you answer some questions “yes” acknowledging a serious health condition, then they may decline your application. Other times, if you have a minor or moderate health condition, the insurance carrier may accept your application but charge you a higher premium due to the health condition. The health questions are not standardized, so Insurance Company B may be able to approve you even if you’ve been declined by Insurance Company A.
 

Discount Availability: A discount is often available when more than one member of a household is enrolled in a Medicare Supplement with the same insurance company. Not all companies offer this type of discount, but many do, and in a competitive environment, it’s becoming increasingly popular for insurance companies to offer this kind of discount. The discount is typically about 5%, but some companies have been aggressive offering up to a 12% discount per person. This can give you significant savings. Some insurance companies have gotten even more innovative in their discount offerings by offering a household discount as long as you simply live with another adult - even if that other adult is not enrolled in a Medicare Supplement with the insurance company. This discount can be especially helpful for those who have a spouse who is not yet on Medicare.
 

Age: Every insurance company is going to ask you your age - but for some insurance companies, the way that your age plays into your premium may differ. There are three distinctions that can be made here:
 

Attained-Age: If an insurance company offers “Attained Age” policies, then your rate is based on your current age and will continue to be based on your age as you get older. In short, expect to pay more as you get older, as the rate table will change due to inflation, and you will enter into new age brackets that have higher prices.
 

Issue-Age: If an insurance company offers “Issue-Age” policies, then your rate is based on the age you were when you enrolled. It will not get higher based on age, but it may get higher based on inflation. In short, your age only matters to determine your initial rate - as any rate increases in the future will not be determined by your age.
 

Community: A community plan charges everyone the same price, regardless of their age. Premiums go up based on inflation, but not due to individual age increases.

Note: Some community-rated companies offer various discounts based on age, making their policies similar to the attained-age companies. They are still technically Community-Rated because the discount is taken off of the standard community rate - and ages that no longer qualify for the discount will all pay the same.

IS THERE EVER A GOOD REASON TO CHANGE MY MEDICARE SUPPLEMENT PLAN?

You can change your supplement plan at any time of the year and as often as you’d like to, as long as you can qualify for the new Medicare Supplement plan.

MEDICARE SUPPLEMENT WITHOUT HEALTH QUESTIONS (PART 1)? MEDIGAP OPEN ENROLLMENT

When can you get a Medicare Supplement without health questions?

There are two different ways.

First (Part One) is during your Medigap Open Enrollment.

When: The Medigap Open Enrollment is a 6-month period of time. It begins on the first day of the month in which you’re (a) 65 or older and (b) enrolled in Medicare Part B. To be clear: if you delay enrollment into Medicare Part B until after “turning 65,” for example, when you turn 68, you’ll still get an open enrollment. In this example, your Open Enrollment will start on the first day of the month in which your Medicare Part B starts at age 68.

Why this helps you: During this period of time, there are no health questions for you when you apply for your Medicare Supplement plan, and and there are (normally) no excluded pre-existing conditions with your Medicare Supplement plan (the only exception for this is those entering without creditable coverage, in which case the medicare supplement company may have a waiting period for those pre-existing conditions). In addition, the company can not charge you a higher rate than they would normally charge someone else who has no health conditions.

For a lot of people, this period of time begins the month in which they turn 65. For others who delay enrollment into Medicare Part B due to employer coverage (or other reasons), this enrollment period starts later.

MEDICARE SUPPLEMENT WITHOUT HEALTH QUESTIONS (PART 2)? GUARANTEED ISSUE

There are 7 different “Guaranteed Issue” situations. All of them are unique and may be applicable to you if you are trying to apply for a Medicare Supplement without answering health questions.

Here is a summary of the seven different guaranteed issue scenarios:

1. You are in a Medicare Advantage Plan, and that plan will no longer be available to you either because it is no longer available in your county, or because you move out of the county in which it was available and it is not available in the new county that you’ve moved to.

2. You have Medicare A + Medicare B + Employer Group Health Plan or Union Coverage which is secondary to Medicare A & B, and the employer group plan is ending.

3. You have Medicare A + Medicare B + a Medicare Select Policy (a Medigap policy with a network of hospitals) and you move out of the Medicare Select service area.

4. You joined a Medicare Advantage plan when you were turning 65 and you’ve decided that you’d like to switch back to regular Medicare with a Medicare Supplement within the first year of being on your Medicare Advantage plan.

5. You had a Medicare Supplement. But, you dropped it and joined a Medicare Advantage plan, and this was your first time in a Medicare Advantage plan. Now, you’d like to switch back to how you had things before, and you are within a year of when you first made the switch.

6. You have a Medicare Supplement plan, but the company went bankrupt and you lost your coverage through no fault of your own.

7. You leave a Medicare Advantage Plan or drop a Medigap (Medicare Supplement) policy because the company hasn’t followed the rules, or it misled you.

Questions and answers on this Medicare Information Site were prepared and written by Scott Shafran, owner of StartMedicareRight.com. Scott has been helping people with Medicare and Medicare-related health insurance since 2010.

HEALTH QUESTIONS FOR MEDICARE SUPPLEMENTS?

Do all Medicare Supplement companies ask the same standard questions? What should I expect to have to answer when applying for a Medicare Supplement?

First of all, not everyone will need to answer health questions. If you qualify for the Medigap Open Enrollment, then you will not be subject to health questions. Typically this occurs when you are “new to Medicare Part B” and at least 65 or older.

Secondly, in situations where you will need to answer health questions, the companies each have different questions that they will ask. Let’s say you are 69 years old, and you apply for a new Medicare Supplement plan with Company A because their rates are $40 less per month for the same plan you currently have. But, because you have a health condition requiring three different medications related to your heart, that insurance company has denied your coverage.

You shouldn’t give up at this point. There may be other companies who will approve you, even though Company A did not approve your application. Try to apply with Company B. Perhaps you’ll only save $32 per month, rather than $40 per month, but that is still a significant savings and worth exploring.

WHAT IS A MEDICARE PART D PLAN?

HOW CAN I ENROLL IN A MEDICARE PART D PLAN?

You can get it through either a stand-alone Medicare Part D plan (common when you are keeping Original Medicare with a Medicare Supplement), or you can get Part D coverage through a Medicare Advantage plan (if offered where you live).

If you choose to have Medicare Parts A & B as your Primary insurance + a Medicare Supplement (Medigap) plan as your secondary insurance, then you’ll want to pick a Stand-Alone Part D Plan for your prescription coverage.

If you choose to get a Medicare Advantage plan, then you can (normally) get Part D coverage included with your Medicare Advantage plan. There are two types of Medicare Advantage Plans: MAPD plans (Medicare Advantage Prescription Drugs), and MA-Only plans (Medicare Advantage Plans without Prescription Drugs).

HOW DOES MEDICARE PART D WORK? WHAT IS THE "PATTERN"?

Medicare Part D has four phases. This is the case regardless of whether you get your Medicare Part D through a Stand-Alone Part D Plan (a PDP) or a Medicare Advantage Plan (MAPD).

Each plan has 4 phases.

First, the annual deductible (which can be as low as $0 and as high as $505 in 2023). Some plans will only apply the deductibles to certain tier levels - and waive the deductible on common generics.

Second, there is the Initial Coverage phase. This stage has copays for your medication based on the drug’s tier level. For example - a tier 1 medication may be a common generic medication with a copay of $4, or $1, or whatever dollar amount the insurance company sets. In 2022, you are in this stage until you and the insurance company have together spent $4,660 on medication.

Third, there is the Coverage Gap. If you’ve passed through the Initial Coverage level because your medication costs have reached $4,660, you enter into the third phase - the coverage gap. This is commonly called the “donut hole.” In this third phase, you pay 25% of the cost of medication. You receive a 70% credit from the drug manufacturer, and the insurance carrier pays the remaining 5%. You stay in phase three until you reach the “true out of pocket” (TROOP) costs of $7,400.

Note: The True Out of Pocket (TrOOP) threshold of $7,400 is reached when the following amounts add up to $7,400.
(a) The Amount You’ve Spent
+ (b) The Amount of “credit” you’ve received from the drug manufacturer during the coverage gap phase (i.e. 70%).

People often reach the $7,400 “threshold” earlier than expected because of the 70% credit, which counts towards the True Out of Pocket.

Fourth, there is the Catastrophic Coverage phase. During this phase, you pay the greater of 5% or $10.35 (Brand) or $4.15 (Generic) for your medication.

WHEN DO THE "PHASES" OF MEDICARE PART D BEGIN AND END?

The four phases of the Medicare Part D program begin and end during each calendar year.

Let’s say you join Medicare and pick up a Medicare Part D plan in July. Because you take a few medications, you go through phase one (deductible) and phase two (initial coverage) by December.

In January, you will not hit phase three, as the “phases” start all over, even though you were only in the plan for 1/2 of the year.

WHAT IS MEDICARE PART C? (MEDICARE ADVANTAGE)

Medicare Part C is simply another term for a Medicare Advantage plan.

If you enroll in a Medicare Advantage plan, then you have Medicare Part C. If you enroll in Medicare + a Medicare Supplement + a separate Part D plan, then you do not have Medicare Part C.

Medicare Part C is private insurance offered by private insurance companies. When you enroll in a Medicare Part C plan, your primary insurance is no longer original Medicare A & B - your primary insurance is the private insurance company that offered the Medicare Advantage plan.

To be clear - a Medicare Advantage plan is not a plan that helps pay what Medicare doesn’t - rather, it pays in place of Medicare. Often, advantage plans offer many benefits above and beyond what you would have had with “just Medicare” - but it’s important to know that the advantage plan is not coordinating benefits with Medicare, as the advantage plan is your primary coverage.

HOW DOES A MEDICARE ADVANTAGE PLAN (MEDICARE PART C) WORK?

A Medicare Advantage plan, at the most basic level, can be described as an alternative to traditional Medicare.

A Medicare Advantage plan is a private health insurance plan with a Medicare Contract. A Medicare Advantage plan is offered by private health insurance companies, and their plans are approved by Medicare for a contract year.

Can any random insurance plan also be called Medicare Advantage? No. A Medicare Advantage plan must be approved by Medicare - i.e., there are certain standards that they must meet in order to be able to offer an insurance plan and call it a Medicare Advantage plan.

When you enroll in a Medicare Advantage plan, you are electing to follow the plan’s rules and use the plan’s network. Also, you are agreeing to the list of copays and co-insurances listed in the Medicare Advantage Plan’s summary of benefits.

This plan becomes your primary insurance, and original Medicare (Medicare Parts A & B) is no longer your primary insurance.

The Medicare Advantage Plans are calendar year plans and often change some benefits on a yearly basis.

ARE ALL MEDICARE ADVANTAGE PLANS THE SAME?

No, they are not all the same.

In each county, there may be as few as 0 medicare advantage plan options, and as many as 50 or more medicare advantage plan options.

And each option will have it’s own summary of benefits, and it is rare (impossible?) to find two plans that are exactly the same.

Often, each insurance company will offer multiple different kinds of plans.

The key to everything is the summary of benefits, which outlines your copays and responsibilities if you choose to enroll in the plan.

Each plan’s summary of benefits will describe the plan’s coverage in detail. By comparing multiple options, you’ll be able to identify the strengths and weaknesses of the competing plans.

No, you will not.

Because the Medicare Advantage plan becomes your primary insurance, you will use your Medicare Advantage plan card any time you see a medical provider (including the pharmacy in most cases).

However, you should still keep your Medicare card in a safe place. You may need it in the future, especially if you decide to change plans in the future.

WHAT DOES A MEDICARE ADVANTAGE PLAN COVER?

Medicare Advantage plans are unique insurance plans. The county that you live in may have different plan options than a neighboring county. In addition, the Medicare Advantage plan that you pick this year may have a different benefit structure next year. Will it improve? Maybe. Will it diminish in coverage? Maybe.

Because the Medicare Advantage plans are not standardized, there is no possible way to summarize the coverage offered in the Medicare Advantage plans, as they will be unique offerings in your residential area.

IN WHAT WAYS ARE MEDICARE ADVANTAGE PLANS DIFFERENT THAN ORIGINAL MEDICARE?

Medicare Advantage plans are plans are normally network-based plans - like an HMO or a PPO.

Original Medicare is accepted by the majority of doctors and hospital nation-wide. There are not too many providers who do not accept Medicare. When you join a Medicare Advantage plan, you are joining a network-based plan, and the network is usually a local network established by the insurance company that you’ve picked. Because they are network based plans, you should expect that some providers local to you will accept the insurance, and you should expect that some providers local to you will not accept the insurance. It will be very important for you to check the network status of the provider prior to utilizing that provider for service.

There are two main types of networks: an HMO and a PPO.

An HMO plan is a plan with a network, and you must use the network otherwise the claims will not be approved (exception: emergency).

A PPO plan is a plan with a network of providers, but with some flexibility to choose providers outside of the network, normally at a higher cost (and sometimes with an added deductible).

Medicare Advantage plans have plan documents called the Summary of Benefits where they list their copayment structure for the plan for the calendar year.

So, whereas Medicare’s medical expenses generally run on an 80%/20% system, the Medicare Advantage plans typically offer a more structured copayment system (i.e., $10 for primary care doctor, $45 for specialist, etc.).

These benefit structures can and do change on a yearly basis. It is important to pay attention to these changes so that you can ensure that you know what to expect.

To summarize: Original Medicare is accepted by a majority of providers nation-wide, and is generally stable in benefits, and a Medicare Advantage plan is designed for local use with select providers, and can change on a yearly basis (while offering coverage which is at times better than original medicare by offering set copays).

WHAT COMPONENTS ARE STANDARD IN A MEDICARE ADVANTAGE PLAN?

There are several standard components in a Medicare Advantage plan, but one of the most important components is the Out-of-Pocket Maximum.

Because the Medicare Advantage plans still have copays and/or coinsurance - many of which can be significant - the Medicare Advantage plans are required to have a “safety net” for those who enroll into a plan.

In addition to the maximum out-of-pocket benefit, the Medicare Advantage plans must also cover all of the services that Original Medicare covers except for Hospice care (Original Medicare will still cover hospice). You always have coverage for emergency and urgent care in an advantage plan.

The key difference is that the Medicare Advantage plan does not have to cover the services in the same way as original medicare would have.

Let’s use an example: With Original Medicare, when you want to go see a specialist for an eye condition, you can do so without getting a referral from your Primary Care Doctor. However, under a Medicare Advantage plan, they are required to cover specialist office visits, but they may require a referral first. This is how the advantage plan “manages care” (and saves money).

To be clear, the above is merely an example of how the advantage plan can be different than Original Medicare while still covering the same components that original medicare covers. Not all advantage plans require referrals in order to see a specialist.

Finally, each Medicare Advantage plan will offer a Summary of Benefits document. This document will outline how you will be covered and will list your copays or coinsurance on just about everything you can think of, including (but not limited to): primary care doctor copays, specialist copays, ER copays, MRI copays, Hospitalization Copays, Lab Copays, etc. The summary of benefits document is very important to keep and review.

HOW OFTEN CAN I CHANGE A MEDICARE ADVANTAGE PLAN?

Most people who are enrolled in a Medicare Advantage plan are able to change their Medicare Advantage plan during the Annual Election Period (AEP).

This period of time is at the end of each calendar year - currently from October 15 thru December 7th. The new plan begins on January 1st of the following year.

You are allowed one change during this time, and the way the Medicare rules work is that the “last application sticks.” What do I mean by this?

Let’s use an example. You are in a Medicare Advantage Plan now, and on October 28th you decide to switch plans to a new Medicare Advantage Plan. You fill out the paperwork, sign it, and the agent turns it in. All set for next year, right? But, mid-November you find out about another different plan that sounds better. You check out this plan, and you like it better than the one you signed up for on October 28th. All you need to do is enroll (You must do so by the deadline - 12/7) and the one you signed up for on October 28th will be null and void as the “last application signed is the one that sticks.” So, the application you signed mid-November will be your new plan starting on January 1st of the following year.

But, do you need to wait until October 15th to switch plans? For most people in most situations, if you are enrolled in a Medicare Advantage plan and you want to switch your plan, you will likely need to wait until this election period.

There are (many) exceptions to this rule, and we cover many of those exceptions here. If you are “stuck” in your plan and would like to see if you can “get out of it” - then this page may show you an option or two.

WHAT OTHER OPPORTUNITIES DO I HAVE TO CHANGE PLANS OR ENROLL IN A MEDICARE ADVANTAGE PLAN?

There are many, many exceptions that allow people to make plan changes and elections mid-year. I’m going to list the various opportunities in summary format.

This list is not 100% exhaustive, but it covers most situations. If you are in a Medicare Advantage plan now and you know that you would like to change plans, it’s best to contact an agent who can help you navigate the various enrollment guidelines.

Turning 65 and New to Medicare

Turning 65 and not New to Medicare

Medicare Advantage Open Enrollment Period (from Jan 1 - March 31) allows you to disenroll from your Medicare Advantage plan and make a change to a different plan, or, you can disenroll from the Medicare Advantage plan and go back to Original Medicare.

5-Star Special Election Period

Leaving Employer Coverage and eligible for Medicare

Eligible for Medicaid and want to change plans mid-year

Loss of Medicaid eligibility

Eligible for Extra Help and wanting to change plans mid-year

Loss of Extra Help

Change of living situation to a long-term care facility

Change in residence, causing a loss of plan coverage

Loss of plan due to insurance plan leaving my county

Diagnosed with a Chronic Condition (eligible for a Chronic Condition Special Need Plan in my area, if available).

First-year in Medicare Advantage plan and qualifies to dis-enroll because of the “trial right”

There are a few more obscure “special situations” but this list covers the most common. As always, feel free to contact us if you are wanting to make an immediate change to your Medicare Advantage plan and aren’t sure how to do it.

CAN I GET A MEDICARE ADVANTAGE PLAN AND A MEDICARE SUPPLEMENT PLAN?

No, you can not.

A Medicare Supplement will only coordinate benefits with Original Medicare. In other words, they will only pay on bills that Medicare first processes and pays their portion, if applicable (exception: emergency foreign travel).

There is no Medicare Advantage plan out there that would pay their portion, then send the “remaining balance” to a supplement company to pay. Once the Advantage Plan pays their portion, it is your responsibility to pay your portion.

If you enroll and get approved for a Medicare Advantage plan, you need to cancel your Medicare Supplement plan.

Similarly, if you enroll in and get approved for Medicare Supplement plan, you need to cancel your Medicare Advantage plan (normally, this is accomplished by enrolling the your stand alone Part D plan, which automatically dis-enrolls you from your Medicare Advantage plan).