Medicare Advantage

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Coverage and Eligibility

Medicare Advantage plans (also known as Medicare Part C) provide these types of coverage:

Part B– Medical

And typically Part D – Drug

Live within the plan’s service area

Part A – Hospital

Some plans may also cover additional benefits Original Medicare doesn’t cover, such as routine vision and/or dental, health and wellness programs and prescription drugs.
A beneficiary must be enrolled in Original Medicare to enroll in a Medicare Advantage plan. Part A and Part B are part of the federal Medicare program.
A beneficiary must meet the following conditions to be eligible for a Medicare Advantage plan:

Eligible for Medicare

Enrolled in both Medicare Part A and Medicare Part B

Beneficiaries can return to original Medicare during the Annual Enrollment Period (AEP) from October 15- December 7.During the Open Enrollment Period (OEP), current Medicare Advantage members can make a one-time plan change to another Medicare Advantage plan, or return to Original Medicare and add a Part D prescription Drug plan.

Dual Eligibility

A beneficiary enrolled in both Medicaid and Medicare is referred to as a “dual eligible” beneficiary. Dual eligible beneficiaries receive assistance with Medicare premiums through Medicare Saving Programs (MSPs) and may receive full Medicaid benefits.

Dual eligible beneficiaries can make a one- time plan change quarterly during the first 3 quarters of the calendar year until the end of 2024. The change will be effective the next month.

Qualified Medicare Beneficiary (QMB) Program

Helps pay for Part A and/or Part B premiums, deductibles, coinsurance and co-payments

Specified Low-Income Medicare Beneficiary (SLMB) Program

Helps pay for Part B premiums

Qualifying Individual (QI) Program

Qualified Disabled Working Individual (QDWI) Program

Pays the Part A premium for certain people who have disabilities and are working.

Quailfied Medicare Beneficiary Program +(QMB+)

Same as QMB, but with full Medicaid

Note: Categories may vary by state.

Full Benefit Dual Eligibles (FBDE)

Plan Types

Types of Medicare Advantage Plans

These are the primary types of Medicare Advantage plans:
Note: Most of the different Medicare Advantage plans include prescription drug coverage.

Health Maintenance Organization (HMO)

An HMO plan requires members to receive care from contracted network providers. Some HMO plans require specialist referrals.

Health Maintenance Organization with a Point of Service Option (HMO-POS)

HMO-POS plans allow for certain services to be received out-of-network (OON). There may be a higher cost share for using OON services.

Preferred Provider Organization (PPO)

PPO plans offer members the flexibility to use network providers or receive care OON at a higher cost.

PFFS plans allow members to receive services from any Medicare approved provider who agrees to accept the MA plan’s terms for payment. Providers can decide on a visit-by-visit basis whether they will accept the plan.

Private Fee-For-Service (PFFS)

Medicare Special Needs Plans (SNPs)

An HMO plan requires members to receive care from contracted network providers. Some HMO plans require specialist referrals.

Medicare Medical Savings Account (MSA)

A Medical Savings Account is a combination of a highdeductible health plan and a bank account where the beneficiary’s health insurance plan deposits a certain amount of money per year. The beneficiary uses the money in their account to pay for Medicare Part A and Medicare Part B expenses, and when their plan deductible is met, the plan pays for any further Medicare-covered services. MSAs do not offer Medicare Part D prescription drug coverage.

A Medicare Cost Plan is a type of Medicare Plan similar to a Medicare Advantage Plan, where private health insurance carriers contract with Medicare to deliver Original Medicare Benefits (Part A and Part B) some cost plans have contracted networks to deliver health care services.

Cost Plans

A PACE Plan is a Medicare and Medicaid program that allows beneficiaries needing a nursing home level of care to receive those services within a community setting, instead of going into a nursing home or other facility. The program coordinates all care.

PACE Plans

Medicare Supplement Plan (Medigap)

Medicare Supplement insurance complements Original Medicare to cover medical out-of-pocket costs like deductibles and co-pays. Enrollees must have Medicare Part A and Part B. Medicare Supplement plans do not cover prescription drugs or include supplemental benefits like dental, vision, and hearing. These plans are not compatible with Medicare Advantage plans, and have higher premiums. Medicare Advantage plans must provide the same level of coverage as Original Medicare, with the exception of hospice care (which is still covered by Part A). Some plans may also cover additional benefits Original Medicare doesn’t cover, such as routine vision and/or dental, health and wellness programs and prescription drugs.

Plan Costs

All Medicare Advantage plans must cover Medicare “medically necessary services. Some Medicare Advantage plans have a premium, and may have deductibles, co-pays, or coinsurance for some services.
Medicare Advantage plans may also offer additional (ancillary) services such as vision care, dental care, hearing or hearing aids, over-the-counter (OTC) benefits, transportation and/or fitness programs.
Medicare Advantage plans have an annual limit on out-of-pocket expenses that can be incurred by a member. Once this threshold is reached, the plan covers all medically necessary services for the remainder of the plan year. Maximum outof-pocket (MOOP) limits vary by plan.

Plan and Provider Finder

Medicare Plan Finder

ZCARE conducts comprehensive research with its Medicare Plan Finder to help Medicare beneficiaries explore available Medicare Advantage and PDP plans as well as Medigap policies to compare benefit and cost share information.

Find Participating Providers and Formulary Drugs

Additionally ZCARE provides the services to locate in network providers and pharmacies

Enrollment and Election Periods

Annual Election Period (AEP) and Open Enrollment Period (OEP)

The Annual Enrollment Period (AEP)runs from October 15 to December 7. During this time, beneficiaries can switch Medicare Advantage plans, enroll in a Medicare Advantage plan for the first time, or disenroll from their current plan and go back to Original Medicare. Beneficiaries can switch as many times as they like, but the beneficiary’s final selection in prior to the end of AEPis the plan that will become effective January 1.

Important information regarding OEP:

Move out of the plan’s service area

Live in an institution (like a nursing home)

Enrollment period – January 1st – March 31st

MA plan members can disenroll from current MA plan to enroll in a different MA plan, or go back to Original Medicare with, or without, enrolling in a Part D plan. Plan members can also return to Original Medicare and purchase a nonguaranteed issue Medicare Supplement plan.

Marketing to encourage beneficiaries to switch plans is not permitted during OEP

Special Election Period (SEP)

An MA Special Enrollment Period (SEP)allows a beneficiary to change Medicare coverage or enroll in an MA plan outside of the initial enrollment period or other enrollment periods. Some examples include:

Lose other creditable prescription drug coverage

Have Medicaid (mainly discontinued in 2025)

Qualify for Extra Help (mainly discontinued in 2025)

Medicare Part B Late Enrollment Penalty

If the beneficiary doesn’t enroll in Medicare Part B when they’re first eligible for Medicare the beneficiary can be subject to a Late Enrollment Penalty, which is added to their monthly Medicare Part B premium.

The penalty is 10%of their monthly premium. Their monthly Part B premium will go up 10%for each full 12-month period that they could have had Medicare Part B but did not take it. The beneficiary will pay this higher premium as long as they have Medicare Part B.

They may not have to pay the penalty if they qualify for a Special Enrollment Period and have been enrolled in creditable medical coverage, such as an Employer health plan.

Medicare Part D Late Enrollment Penalty

If the beneficiary doesn’t enroll in Medicare Part D Prescription Drug Plan (PDP) when they’re first eligible for Medicare or have creditable prescription drug coverage, the beneficiary can be subject to a Late Enrollment Penalty, which is added to their monthly Medicare Part D premium.

They may not have to pay the penalty if they qualify for a Special Enrollment Period and have been enrolled in creditable prescription drug coverage, such as coverage through the VA or an employer health plan. Additionally, those who qualify for Extra Help (Low Income Subsidy) are exempt from the Part D Late Enrollment Penalty.

Low Income Subsidy (LIS)

Low Income Subsidy (LIS) - also known as “Extra Help”

Eligible beneficiaries who have limited income may qualify for a government program that helps pay for Medicare Part D prescription drug costs. Medicare beneficiaries receiving the Low-Income Subsidy (LIS) get assistance in paying for their Part D monthly premium, annual deductible, coinsurance, and copayments.

Some people get Extra Help automatically. These include people who are enrolled in Medicaid and Medicare (often called dual eligible), those receiving Supplemental Security Income (SSI), and those who qualify for a Medicare Savings Program. These individuals do not need to apply for the program.

Anyone else who is not already enrolled in the benefits noted above must apply to Social Security to receive Extra Help. To qualify for Extra Help with Medicare prescription drug plan costs, they must meet certain income and asset requirements. If a beneficiary is not already receiving this additional assistance, they should contact 1-800-MEDICARE (24 hours a day, 7 days a week).