Co-founder of Elite Insurance Partners and Medicare FAQMedicare Learning Resource Center for all Medicare beneficiaries.
It’s not always possible to make changes to your Medicare Advantage plan. Hence, it is important for those who have this type of coverage to be aware of the details of their plan every year.
Additionally, it is important to know the time frame when you can make adjustments. Below, I explain some of the top reasons why people swap or leave Advantage plans and when they can take these actions.
Favorite Physician Leaves Network
Medicare Advantage plans include practitioner networks. When a Doctor Advantage plan leaves the network, beneficiaries usually find out through Annual Notice of Change (ANOC) Letter, which outlines coverage changes for the next year.
The changes will be effective from January 1. Those enrolled in Advantage plans can expect to receive their ANOC in September, shortly before the start of the annual enrollment period.
You may know the annual enrollment period as Fall Open Enrollment. It runs from 15 October to 7 December every year. This enrollment period gives Medicare Advantage beneficiaries the opportunity to leave their Advantage plan to switch to another Advantage plan or return to Original Medicare (Parts A and B) for the next year. If they choose to leave their Advantage plan, they also have the option of taking a Part D prescription drug plan.
If your ANOC informs you that your preferred physician will no longer be a part of your network, the annual enrollment period is the right time to find an Advantage plan that will include coverage for visits. if your doctor Medicare accepts assignmentYou may want to leave your Advantage plan and return to original Medicare.
The plan no longer covers prescriptions or supplements
Another common reason beneficiaries leave their Medicare Advantage plan is learning that their medications or supplements are no longer covered. Yours The Annual Notice of Change also informs you about whether your plan will cover your medication for the next year.
Each Medicare Advantage or Part D prescription drug plan comes with: formulary, which is a list of drugs that get coverage through the plan. If the drugs you take no longer get coverage, you could face huge costs.
When your plan no longer covers your medications, one option is to find another Advantage plan during the annual enrollment period, which includes them in its prescription drug formulary. Your other option is to leave your Advantage plan, return to original Medicare, and choose a Part D plan that covers your medications.
Change drug tier for covered drugs
Formularies change every year, which means your share of prescription drug prices could follow suit. Your annual Notice of Change letter will let you know if the drugs you are taking are moving to another drug tier. If your drug tier number is higher than in the current year, you’ll pay more in payments and reach the donut hole faster.
In this case, you can shop for another Advantage plan that makes your medicines more affordable. Alternatively, you can leave your plan and combine Original Medicare with an appropriate Part D plan for the next year.
The scheme is no longer affordable to the beneficiary
In addition to drug costs, you’ll also want to look at other out-of-pocket costs on your Advantage plan. These include monthly premiums, maximum out-of-pocket amounts, and prescription drug deductibles. Keep in mind, you still have to make your payment Part B Premium In addition to the premium for your Advantage plan, if applicable.
For 2022, the maximum prescription drug plan deductible is $480. This means that each plan sets a dollar amount at or below that limit that beneficiaries must pay out of pocket before the initial coverage phase.
The initial coverage phase is when your plan starts out with more coverage. The following two steps are donut hole and catastrophic coverage — the latter of which covers the bulk of your generic and name-brand drug costs.
If the added cost of your plan now seems too much for you, you can use the annual enrollment period to make changes. Alternatively, if you feel that your plan is not affordable for you after the first of the year, you have another opportunity to choose a different coverage.
The Medicare Advantage open enrollment period runs from January 1 to March 31 each year. Only the beneficiary who currently has Advantage plans can make changes during this period. You can enroll in a new Advantage plan or skip Advantage altogether to return to Original Medicare, with or without Part D prescription drug coverage.
This enrollment period is in contrast to Fall Open Enrollment when the beneficiary can make multiple changes and the last change becomes effective. During the Medicare Advantage open enrollment period, you can make only one change. Therefore, it is important to spend time making a careful decision, as this will be the coverage you will have for the rest of the year.
Special Enrollment Period for Medicare Advantage
Certain life events qualify Advantage participants for a special enrollment period. This includes:
• Going outside the coverage area of the plan.
• The plan closes in the beneficiary’s territory.
• Excluding employer or union coverage to enroll in Medicare.
• Losing health coverage through an employer or spouse.
Different rules and deadlines apply for each enrollment period.
Making the Best Choice for Your Coverage
Knowing when to make changes to your Advantage plan can lead to long-term savings. You want to be prepared first, so spending time researching your plan options is a wise investment.
Over time, your health and financial needs may change. Please remember that you do not have to stick to a plan that is no longer right for you.
The information provided here is not investment, tax or financial advice. You should consult a licensed professional for advice regarding your specific situation.