page index ---

• Original Medicare and Medicare Advantage Plans are NOT the same.

• The Annual Election Period (AEP) occurs EVERY YEAR from October 15 - December 7.

• AEP - DOES NOT impact those who are enrolling in Original Medicare (Parts A & B)  for the first time.                

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 MEDICARE ADVANTAGE PLANS 

• You will keep your original Medical Part A (for hospital coverage) if you choose an Advantage Plan for your Supplement Health Insurance Coverage.

• Advantage Plans will include Part B (Original Medicare), and  Part D (Supplemental Prescription Drug Plan).

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PLAN C - MEDICARE ADVANTAGE

• Medicare Advantage Plans are offered by Private Insurance Companies (HMOs or PPOs).

• Advantage Plans cover most costs, but coverage is LIMITED  Medicare Approved Charges. You may be responsible for additional out-of-pocket expenses if your doctors charge more than what is allowed by Medicare. 

•  You can purchase an Advantage Plan that includes  Prescription Drug Coverage (Part D).

• Some physicians and medical facilities may not accept Advantage Plans.  Some Advantage Plans are not offered in all geographical areas of the country. 

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SWITCHING PLANS & PRESCRIPTION DRUG COVERAGE

Switching from Medicare Advntage to Original Medicare Parts A & B

Purchasing Plan D - Prescription Drug Coverage

 You will not pay a Part D penalty when you enroll in a new Medicare Part D prescription drug plan or a new Medicare Advantage plan with drug coverage 

within (63) days of leaving your previous Medicare Advantage plan.

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Coverage Rules

• Creditable Coverage: Your Medicare Advantage plan with prescription coverage counts as "creditable coverage," meaning it is at least as good as standard Medicare Part D.
• The 63-Day Rule: You must not go 63 days or more in a row without creditable prescription drug coverage. 
• Avoiding Penalties: If you switch to Original Medicare and sign up for a stand-alone Part D plan within that 63-day window, your continuous coverage is maintained and no late penalty applies.
• Triggering a Penalty: If you wait longer than 63 days without drug coverage after dropping your plan, a permanent late enrollment surcharge will be added to your future Part D premiums. 

SUPPLEMENTAL MEDICAL  (MEDIGAP)  PLANS ARE PURCHASED FROM 

PRIVATE INSURANCE COMPANIES. 

 PLANS -----   D, F, G  

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PART D - Prescription Drug Coverage 

• Provided only by Private Insurance Companies who have contracts with the federal government.

• Advantage Plans include Plan D coverage for prescription drugs. 

• Prescription drug costs are based on the designated formularies of the drug (brand-name, or generic) and on the Tier Category to which the drugs are assigned by the drug manufacturers. 

• Vaccines, such as, Shingles, Diphtheria, Tetanus, Pertussis are not covered under Medicare.   However, they are generally covered under a stand-alone Part D (Drug Plan)  or a Medicare Advantage that includes Plan D.   

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IS YOUR PHARMACY AN IN-NETWORK -- OR -- OUT-OF-NETWORK?

It is "essential" that you know what type of PHARMACY

 (as defined by your Plan D) that you are using for your medications.  

The co-pays can be hugely different depending on the local 

pharmacy you use. 

• Preferred in-network pharmacy: most often offer prescriptions at lowest  cost-sharing amount.

• Standard in-network pharmacy: typically, prescriptions will have a higher  cost-sharing amount.

• Out-of network -pharmacy: at an out of network pharmacy you will not be able to utilize your prescription drug coverage. You will pay for the cost of the prescription. 

• Mail-Order  (Least Expensive) 

PENALTY APPLIED

•  If you choose NOT to purchase Plan  D for Prescription Drug Coverage when you are eligible for Original Medicare a life-long penalty can be imposed. 

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PLAN F - Supplemental  Medical Coverage to Parts A & B of Medicare. 

 to Original Medicare Parts A & B. 

This plan pays 100% of any excess charges not covered by

Original Medicare including your annual deductible for Plan B.               _____________________________________________

PLAN G -  Supplement Medical Coverage to Parts A & B of Medicare. 

• This plan is nearly identical to Plan F and covers excess costs from healthcare providers (charges exceeding Medicare-approved charges).  This plan covers 100% of Plan A excess amounts.

• This plan covers 100% of Plan B excess amounts, but it does not pay the annual deductible required by Plan B. 

•  Excess charges occur when medical providers charge more than what Medicare allows. By law, providers can't charge more than 15% of what Medicare covers.

 During the AEP those who are already enrolled in Medicare can 

RE-EVALUATE their coverage and make 'some' changes to their Medicare Advantage Plan C,  and to Prescription Drug Coverage, Part D.   

AEP - ANNUAL ENROLLMENT PERIOD

October 15 – December 7

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WHAT Can You Change During the AEP?

• Switch from Original Medicare to Medicare Advantage, or vice versa.
• Switch from one Medicare Advantage plan to another Advanatage Plan.

• Medicare Advantage plans (Part C) never use medical underwriting or health questions to accept or deny applicants, as long as you apply during a valid enrollment period and live in the plan's service area.

• Switch from one Medicare Part D (prescription drug) Plan to another.  If you did not enroll in a Medicare Part D (Prescription Drug) Plan when you were first eligible for Original Medicare; you can do it during the Open Enrollment period although a late enrollment penalty fee may apply.

• If you want to switch to a Medicare Advantage (Part C) Plan, you must meet some basic criteria.

You must be enrolled in Original Medicare Parts A and B.

You must live in the plan’s service area.

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(AEP) Annual Enrollment Period (October 15 – December 7): 

• Switch from one Medicare Advantage plan to another, or return to Original Medicare. Changes take effect on January 1.

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Switching from Advantage Plan to Original Medicare

Acquiring Supplement Coverage Plans Needed

 Switching from Medicare Advantage to Original Medicare is not hard logistically, 

but it has important financial and coverage risks. 

You must wait for specific enrollment periods, and getting a supplemental Medical (Medigap) Plan may require passing health questions (medical underwriting) depending on where you live.

Key Risks to Consider

• Prescription Drug Coverage Original Medicare leaves you responsible for about 20% of medical costs. While you can drop Advantage easily, insurance companies in most states can deny you a Medigap supplement plan or charge more based on your health history less you are in a trial period or specific state.
• Medigap Underwriting: Original Medicare leaves you responsible for about 20% of medical costs. While you can drop Advantage easily, insurance companies in most states can deny you a Medigap supplement plan or charge more based on your health history unless you are in a trial period or specific state.

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(OEP) Medicare Advantage Open Enrollment Period

 (January 1 – March 31) 

• Switch to a different Medicare Advantage plan or drop it for Original Medicare if you are already enrolled in a Medicare Advantage plan.

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(SEP) Special Enrollment Period 

•  Move or experience specific qualifying life events that let you change plans outside standard dates. 

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Important Rules to Remember

• No Health Rejection: You cannot be turned down or charged more for a Medicare Advantage plan due to pre-existing health conditions (except for End-Stage Renal Disease, with specific rules). 

• Basic Requirements: You must still have Original Medicare (Parts A and B) and live where the plan operates. 

• Medigap is Different: If you switch from Medicare Advantage to a Medigap (Medicare Supplement) plan later, medical underwriting does apply unless you have guaranteed-issue rights. 

                 Annual Notices of Change (ANOC) 

letters or emails are distributed during September.

The ANOC provides a detailed summary of all of the changes

 to your MA plan or Part D plans.

 An Annual Notice of Change (ANOC) from your Medicare Advantage or Part D insurance plan details all upcoming adjustments to your coverage, medical costs, and operational rules that take effect on January 1st. 

Cost Updates

• Monthly premiums: The amount you pay each month to keep the plan.
• Deductibles: The amount you must pay out-of-pocket before the plan starts paying.
• Copays and coinsurance: The set fees or percentages you pay for doctor visits or services.
• Maximum out-of-pocket limits: The absolute most you will pay for medical care in that year. 
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Coverage and Benefits

• Covered services: Any extra benefits, dental, vision, or hearing care added, reduced, or removed.
• Service area: Changes to the geographic regions where the plan operates.
• Star ratings: The official quality score assigned to the plan by Medicare. 
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Doctors and Medications

• Provider networks: Whether your specific doctors, specialists, or hospitals are staying in the plan or dropping you plan.
• Drug formularies: Changes to which your prescription medications are covered.
• Drug tiers: Whether specific drugs moved to a more expensive tier category.
• Pharmacy networks: Changes to local or mail-order pharmacies you can use.                                                                                                                                                                  

GIR - GUARANTEED ISSUE RIGHT

If the ANCO that you receive states that your current MA plan will NOT be available next year, it should inform you that you have a Guaranteed Issue Right (GIR) and you are entitled to a Special Enrollment Period (SEP). It is a federal law that you are entitled to a GIR and SEP.

A GIR prohibits insurance companies from denying coverage or overcharging an applicant for a MA plan or a traditional Medicare supplement (Medigap) policy, regardless of pre-existing health conditions. A SEP allows one to shop for the best deal possible for a Medigap or MA plan.

You should guard against your MA plan provider telling you that your MA plan will cease on 12/31/25 ----- but it can enroll you in a different plan it provides. This is known as "cross walking" and often the recommended plan is more expensive and provides fewer benefits.