Q&A With a Licensed Medicare Advantage Agent

It’s important to get the information you need about Medicare before you enroll, but that can feel like a challenge. We’ve set out to correct that.

Below, Matt Conlon, one of our licensed insurance agents, answers 12 of the most frequently asked questions about Medicare and Medicare Advantage to ensure you understand your coverage options.

agent headshot

“One of the most rewarding things we experience here is that we’re, quite literally, able to change someone’s life for the better! We can find out their situation, see the plans we have to offer in that area, and look for ways to improve things as much as we can for them. What inevitably we find is that we’re not only improving their lives, but also their families’ lives, as well! It really is an amazing thing.”

Matthew Conlon, Medicare Advantage Insurance Agent

1. What is Medicare Advantage?

Medicare Advantage plans are sold by private insurance companies as an alternative to Medicare Part A and Part B (Original Medicare). Medicare Advantage plans must provide at least the same benefits as Original Medicare (aside from hospice care, which is still covered by Medicare Part A), but some Medicare Advantage plans offer additional benefits, such as prescription drug coverage and dental, vision and hearing coverage.

The following chart illustrates how Medicare Advantage coverage and benefits compare to those of Original Medicare.

Original Medicare vs Medicare Advantage

Original Medicare vs Medicare Advantage

Feature/Benefit

Original Medicare

Medicare Advantage

Helps cover some hospital and medical costs

May cover routine dental care

May cover routine vision care

Usually covers prescription drugs

May offer wellness program benefits

Has an out of pocket maximum

You must be enrolled in Medicare Part A and Part B to enroll in a Medicare Advantage plan.

2. Who is eligible for Original Medicare?

If you’re a United States citizen or permanent legal resident for at least five consecutive years, you may be eligible for Medicare if you meet one or more of the following qualifications:

  • You are 65 or older and are eligible for retirement benefits through Social Security
  • You are 65 or older and are eligible for retirement benefits through the Railroad Retirement Board
  • You have a disability and have been receiving disability benefits for at least 24 months
  • You have ALS (Lou Gehrig’s disease)
  • You have end-stage renal disease and require dialysis treatment or a kidney transplant

There may be other circumstances that make you eligible for Medicare not listed here.

3. Who is eligible for Medicare Advantage?

Most people who are enrolled in Original Medicare are eligible for Medicare Advantage, with the exception of people who have end-stage renal disease (ESRD).*

To enroll in a Medicare Advantage plan, you must first enroll in Medicare Part A and Part B and live in the MA plan’s service area. A licensed insurance agent can help you compare plans in your area and get you enrolled. You can speak with a licensed insurance agent now at TTY Users: 711, 24 hours a day, 7 days a week.

* If you have ESRD and would like to enroll in a Medicare Advantage plan, contact an insurance plan and ask if there are Special Needs Plans (SNPs) available to ESRD patients in your area.

4. What does Medicare Advantage cover?

All Medicare Advantage plans must provide at least the same benefits as Original Medicare, which includes coverage for:

  • Inpatient hospital care
  • Inpatient care in a skilled nursing facility
  • Hospice care
  • Medically necessary doctor’s services
  • Durable medical equipment
  • Outpatient care
  • Home health services
  • Mental health services
  • Preventive services and some other medical services

One exception is hospice care, which is still covered by Medicare Part A even if you have a Medicare Advantage plan.

Original Medicare does not typically cover prescription drugs. Most Medicare Advantage plans do.

Additionally, Original Medicare does not typically cover routine dental, vision or hearing care. Some Medicare Advantage plans do.

5. When can I sign up for Original Medicare?

The first time you can enroll in Medicare is during your seven-month Medicare Initial Enrollment Period (IEP). Most people’s IEP begins three months before their 65th birthday.

If you are younger than 65 and qualify for Medicare because of a disability, your Medicare coverage typically begins 24 months after your disability benefits are approved.

If you have ALS, your Medicare benefits begin the first month you have Social Security Disability Benefits.

If you have ESRD and are on dialysis, your Medicare benefits typically start on the first day of the fourth month of your dialysis treatment. People with ESRD usually must manually enroll.

Some people choose to delay their Medicare enrollment if they or their spouse is still working and has group health insurance coverage. If you are still covered by a group health plan, you may be eligible for a Special Enrollment Period. You can sign up for Medicare Part A or Part B at any point while you are still working and have group coverage. Once your coverage or employment ends, you will have eight months to sign up for Medicare without a penalty in most cases.

If you miss your IEP and don’t qualify for a Special Enrollment Period, you’ll have another chance to enroll during the Medicare General Enrollment Period, which runs from January 1 to March 31 each year. Keep in mind, however, that your coverage will not begin until July 1 and you may have to pay late enrollment penalties for as long as you have Medicare.

6. When can I sign up for Medicare Advantage?

There are specific times when you can sign up for Medicare Advantage. If you’re newly eligible for Medicare because you’re turning 65, you can enroll in a Medicare Advantage plan during your Medicare Initial Enrollment Period, which begins three months before your 65th birthday, includes your birthday month, and ends three months after your 65th birthday. You may also sign up during a Special Enrollment Period if you qualify, or the General Enrollment Period.

Remember, you must enroll in Original Medicare before you can enroll in Medicare Advantage.

You also have the opportunity to switch from Original Medicare to Medicare Advantage during the Annual Election Period (AEP), which runs from October 15 to December 7 each year.

Medicare Advantage Open Enrollment Period

During the Medicare Advantage Open Enrollment Period, which runs from January 1 to March 31, Medicare Advantage enrollees may enroll in another Medicare Advantage plan or disenroll from their Medicare Advantage plan and return to Original Medicare.

Note: The Medicare Advantage Open Enrollment Period does not provide an opportunity for people enrolled in Original Medicare to join a Medicare Advantage plan.

You may enroll in Medicare Advantage outside of the times listed above if you have certain special circumstances. You could qualify for a Special Enrollment Period if you’ve recently moved, lost your health care coverage, or faced other qualifying life events. Talk to a licensed insurance agent to learn more.

7. Will a Medicare Advantage plan cover my spouse?

No. Neither Original Medicare or Medicare Advantage provide family coverage, so you and your spouse must enroll in Medicare Advantage plans separately once you’re eligible.

8. How much could I pay out of pocket for Medicare Advantage?

Unlike Original Medicare, Medicare Advantage premiums and out-of-pocket costs are not standardized by the government, so they can vary greatly from plan to plan.

A licensed insurance agent can help you find Medicare Advantage plans in your area and get you a no free, obligation quote.

Get your quote by calling TTY Users: 711.

Keep in mind that even if you’re enrolled in Medicare Advantage you’ll still pay your Medicare Part B premium, which is $135.50 in 2019, unless you must pay a higher premium according to your income.

9. Will every doctor accept my Medicare Advantage plan?

Medicare Advantage plans are not accepted by all doctors and may require you to stay within a network of physicians, providers and hospitals. If you go outside of your MA plan’s network, you could be responsible for 100 percent of the costs for care.

Be sure you fully understand the terms of the plan you are considering before making a purchasing decision.

10. Can I make changes to my Medicare Advantage coverage once I’m enrolled?

You can making changes to your Medicare Advantage coverage during the Medicare Annual Election Period (AEP), which runs from October 15 to December 7. If you make changes during AEP, your coverage will begin January 1 of the following year.

During the Medicare Annual Election Period, you can typically:

  • Enroll or disenroll from a Medicare Advantage plan
  • Switch from Medicare Advantage back to Original Medicare
  • Switch from one Medicare Advantage plan to another Medicare Advantage plan
  • Join, drop or switch a Medicare Prescription Drug plan (if your Medicare Advantage plan doesn’t provide coverage for prescription drugs).

There’s also a Medicare Advantage Disenrollment Period that lasts from January 1 to February 14 each year. If you’re dissatisfied with your Medicare Advantage plan, you can drop it and return to Original Medicare at this time. You can also enroll in a stand-alone Prescription Drug Plan. You may not, however, switch to another Medicare Advantage plan, switch from Original Medicare to a Medicare Advantage plan, or switch Prescription Drug Plans during this period.

11. I’m still working and have group health insurance coverage through my employer. Do I still need to enroll in Medicare Advantage?

If you have health insurance through your or your spouse’s employer, you may qualify for a Special Enrollment Period. If you qualify for a Special Enrollment Period, you can enroll in Medicare outside of your IEP without having to pay late enrollment penalties in most cases.

Since most people do not pay a premium for Medicare Part A, you can remain enrolled in Part A and your group health insurance plan at the same time, and your group plan will help cover your health care expenses.

As long as you’re covered by your employer’s group plan, you can enroll in Part B later. Once you’re enrolled in Part B, you can then enroll in Medicare Advantage.

12. How can I enroll in Medicare Advantage?

Before you can enroll in Medicare Advantage, you must enroll in Medicare Part A and Part B. If you’re not automatically enrolled in Original Medicare three months before your 65th birthday, you can manually enroll by:

  • Calling Social Security at 1-800-772-1213 (TTY users 1-800-0778), Monday through Friday 7AM-7PM
  • Contacting the Railroad Retirement Board at 1-877-772-5772 (TTY users 1-312-751-4701), Monday through Friday 9AM-3:30PM (if you worked for a railroad)
  • Visiting the Social Security website at www.SocialSecurity.gov
  • Visiting your local Social Security office

Typically you are automatically enrolled in Medicare if one or more of the following applies to you:

  • You’ve been getting benefits from Social Security or the Railroad Retirement Board for at least four months before you turn 65.
  • You’ve been getting disability benefits from Social Security for 24 months
  • You’ve been getting certain disability benefits from the Railroad Retirement Board for 24 months
  • You have ALS and receive disability benefits

Once you’re enrolled in Original Medicare, speak with a licensed insurance agent to compare Medicare Advantage plans in your area and get enrolled in one that works for you.

Speak with a licensed insurance agent now at TTY Users: 711 24 hours a day, 7 days a week!

Copyright © 2018 TZ Insurance Solutions LLC. All rights reserved.

MedicareAdvantage.com is a website owned and operated by TZ Insurance Solutions LLC. TZ Insurance Solutions LLC and TruBridge, Inc. represent Medicare Advantage Organizations and Prescription Drug Plans having Medicare contracts; enrollment in any plan depends upon contract renewal.

Plan availability varies by region and state. For a complete list of available plans, please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.

Medicare has neither reviewed nor endorsed this information.