Medicare Advantage Questions & Answers

You can enroll in Medicare Advantage during these periods:

• Initial Enrollment Period (IEP): 7 months around your 65th birthday (3 months before, your birthday month, and 3 months after)
• Annual Enrollment Period (AEP): October 15 - December 7 each year
• Medicare Advantage Open Enrollment: January 1 - March 31 (if you're already in a Medicare Advantage plan)
• Special Enrollment Periods (SEP): If you move, lose other coverage, or qualify for Extra Help

Source: CMS Medicare.gov Enrollment Periods

Yes. To enroll in a Medicare Advantage plan, you must:

• Have both Medicare Part A and Part B
• Continue to pay your Part B premium
• Live in the plan's service area
• Not have End-Stage Renal Disease (ESRD), with some exceptions

Source: CMS Medicare & You Handbook

Yes, you can switch during several periods:

• Annual Enrollment (Oct 15 - Dec 7): Switch to another Medicare Advantage plan or return to Original Medicare
• MA Open Enrollment (Jan 1 - Mar 31): Switch to another MA plan or drop MA for Original Medicare (once per year)
• Special Enrollment Periods: Based on specific circumstances like moving or losing coverage

Changes typically take effect the first day of the following month.

Source: CMS Medicare Advantage Enrollment Guidelines

Medicare Advantage costs include:

• Part B Premium: You must continue paying your Part B premium (standard $174.70/month in 2026, but may be higher based on income)
• Plan Premium: Many plans have $0 premium; others charge a monthly premium on top of Part B
• Deductibles: Some plans have deductibles for medical services and/or drugs
• Copays/Coinsurance: You pay these when you get care
• Maximum Out-of-Pocket: Plans have a yearly limit on what you pay (protects you from catastrophic costs)

Source: CMS Medicare Costs

The out-of-pocket maximum is the most you'll pay for covered services in a calendar year. Once you reach this limit, the plan pays 100% of covered services for the rest of the year.

Key points:

• In 2026, the maximum allowed out-of-pocket limit is $8,850 for in-network services
• Your plan's limit may be lower
• Your plan premiums don't count toward the out-of-pocket maximum
• Services from out-of-network providers may not count

Source: CMS Medicare Advantage Rate Announcements

Most Medicare Advantage plans include prescription drug coverage (called MA-PD plans). Some don't (called MA-only plans).

If your plan includes drug coverage:

• You cannot have a separate Medicare Part D plan
• The plan must cover at least what Medicare's standard drug coverage covers
• You'll have a formulary (list of covered drugs)
• Some drugs may require prior authorization or step therapy

If your plan doesn't include drug coverage, you can join a separate Part D plan.

Source: CMS Medicare Prescription Drug Coverage

All Medicare Advantage plans must cover everything Original Medicare covers:

• Hospital stays (Part A)
• Doctor visits and outpatient care (Part B)
• Lab tests, X-rays, and other diagnostic services
• Preventive services (wellness visits, screenings, vaccines)

Many plans also offer extra benefits Original Medicare doesn't cover:

• Prescription drug coverage
• Dental care (cleanings, fillings, dentures)
• Vision care (eye exams, glasses, contacts)
• Hearing aids
• Fitness programs (gym memberships)
• Over-the-counter (OTC) allowances
• Transportation to medical appointments
• Meal delivery after hospital stays

Source: CMS Medicare Coverage Guidelines

It depends on your plan type:

• HMO (Health Maintenance Organization): You must use network doctors (except for emergency or urgent care). You typically need referrals to see specialists.
• PPO (Preferred Provider Organization): You can see out-of-network doctors but pay less if you use network providers. No referrals needed.
• HMO-POS (Point of Service): Like an HMO, but you can see some out-of-network providers for higher costs.
• PFFS (Private Fee-for-Service): You can see any Medicare-approved provider who accepts the plan's terms.

Always check if your doctors are in-network before enrolling. Networks can change yearly.

Source: CMS Medicare Advantage Plan Types

Special Needs Plans (SNPs) are Medicare Advantage plans designed for people with specific diseases, health conditions, or characteristics. There are three types:

• Chronic Condition SNPs (C-SNP): For people with specific chronic conditions like diabetes, heart failure, or dementia
• Dual-Eligible SNPs (D-SNP): For people who have both Medicare and Medicaid
• Institutional SNPs (I-SNP): For people who live in institutions (like nursing homes) or require nursing care at home

SNPs coordinate your care and often have lower costs. You must meet the plan's eligibility requirements to enroll.

Source: CMS Special Needs Plans Guidelines

Original Medicare (Parts A & B):

• Run by the federal government
• You can see any doctor/hospital that accepts Medicare nationwide
• No prior authorization for most services
• Doesn't include drug coverage (need separate Part D)
• No out-of-pocket maximum (costs can be unpredictable)
• Many people buy Medigap to help cover costs

Medicare Advantage (Part C):

• Run by private insurance companies approved by Medicare
• Must use plan's network (except emergencies)
• May require prior authorization or referrals
• Usually includes drug coverage
• Has an out-of-pocket maximum for predictable costs
• Often includes extra benefits (dental, vision, hearing, gym)
• Cannot have a Medigap policy with Medicare Advantage

Source: CMS Medicare & You Handbook

Yes, you can return to Original Medicare during:

• Annual Enrollment Period (Oct 15 - Dec 7): Disenroll from your MA plan; coverage ends Dec 31, Original Medicare starts Jan 1
• MA Open Enrollment (Jan 1 - Mar 31): Drop your MA plan and return to Original Medicare (once per year)

Important consideration: If you try to buy a Medigap policy after your Initial Enrollment Period, insurance companies can:

• Deny you coverage
• Charge you more
• Make you wait before coverage starts
• Refuse to cover pre-existing conditions

Some states offer Medigap protections. You'll also need to join a Part D plan for drug coverage.

Source: CMS Medicare Enrollment & Disenrollment

Medicare Star Ratings measure plan quality and performance on a 5-star scale:

• ★★★★★ (5 stars): Excellent
• ★★★★ (4 stars): Above average
• ★★★ (3 stars): Average
• ★★ (2 stars): Below average
• ★ (1 star): Poor

Ratings are based on:

• Quality of care and customer service
• How well doctors help members manage chronic conditions
• Member complaints and plan performance
• Health screenings and preventive care
• How members rate the plan

Plans with 4+ stars often qualify for extra enrollment periods and may receive bonus payments from Medicare.

Source: CMS Medicare Star Ratings Program

Free, unbiased help is available from:

• 1-800-MEDICARE (1-800-633-4227): 24/7 help from Medicare; TTY users call 1-877-486-2048
• Medicare.gov: Official site with plan comparison tool and enrollment
• State Health Insurance Assistance Program (SHIP): Free local counseling in every state; find yours at shiptacenter.org
• State Medicaid Office: If you have limited income/resources, you may qualify for help paying costs
• Social Security: 1-800-772-1213 for questions about enrollment and Medicare eligibility

Warning: Be cautious of insurance agents who may pressure you or only show plans they're paid to sell.

Source: CMS Medicare Help Resources