People may lose their Medicare Advantage (Part C) plan for various reasons, including unpaid premiums, relocation, or when a plan is discontinued.
After the loss of a plan, a person may join another Advantage plan, but they may need to do so within a certain time frame. They may also return to Original Medicare, parts A and B.
This article discusses the situations that may lead to the loss of an Advantage plan. It also describes the four main Advantage plans and explains how to join a new plan.
Glossary of Medicare terms
- Out-of-pocket cost: This is the amount a person must pay for care when Medicare does not pay the total amount or offer coverage. Costs can include deductibles, coinsurance, copayments, and premiums.
- Premium: This is the amount of money someone pays each month for Medicare coverage.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before Medicare starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, coinsurance is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
There are several reasons a person might lose an Advantage plan, including:
Nonpayment of premiums
A person can lose their Advantage plan if they do not pay the monthly premiums. The individual must be notified that the plan will disenroll them unless payment is made within a certain time frame.
The plan must offer a grace period of at least 2 months before disenrolling someone. The grace period begins on the first day of the month in which the person did not pay the premiums.
When a person is disenrolled by an Advantage plan, they will receive automatic enrollment in Original Medicare, as long as they have paid the Plan B premiums.
However, if a person wants to enroll in another Advantage plan, they must wait until the next Open Enrollment Period from October 15 to December 7.
Relocation to a different area
If a person moves to an area outside their plan’s service area, they may either join another Advantage plan or return to original Medicare. This tool may help them find a plan in their new location.
A person’s opportunity to enroll in a new Advantage plan depends on when they notified their plan about the move.
When someone notifies their plan before they move, their opportunity to change plans begins the month before they move and ends 2 months after the move.
When an individual notifies their plan after they move, their opportunity to change plans begins the month of notification and ends after 2 months.
A company can stop offering an Advantage plan for various reasons, including in the following scenarios:
- Medicare takes contract action or enforcement against a plan sponsor. In this circumstance, an individual may join another Advantage plan. Medicare determines the time frame in which they may do so on a case-by-case basis.
- Medicare ends a plan’s contract. In this case, a person can change to another Advantage plan. The enrollment period starts 2 months before and ends 1 month after the end of the contract.
- Medicare does not renew the plan’s contract. When this happens, a person may join another Advantage plan during the Special Enrollment Period, which runs from December 8 through the last day of February.
Medicare Advantage is the alternative to Original Medicare. The plans are offered by private companies.
The plans provide the hospital insurance of Part A, the medical insurance of Part B, and, in most cases, prescription drug coverage (Part D).
Some Advantage plans offer additional coverage, such as vision, dental, and hearing coverage.
The four most common types of Advantage plans are:
- Health Maintenance Organization (HMO) plans
- Preferred Provider Organization (PPO) plans
- Private Fee-for-Service (PFFS) plans
- Special Needs (SN) plans
Health Maintenance Organization plans
An HMO plan usually requires a person to choose in-network providers, except in emergencies. Most plans provide prescription drug coverage. They also usually require a referral to see a specialist.
Preferred Provider Organization plans
A PPO plan allows users to choose between in-network and out-of-network providers, but the former cost less. Most plans offer prescription drug coverage and generally do not require a referral to see a specialist.
Private Fee-for-Service plans
A PFFS plan has set amounts on how much it pays providers, as well as set fees for people to pay when they get care. A person may choose from in-network or out-of-network providers, but the former cost less.
Some plans offer prescription drug coverage. They typically do not require a referral to see a specialist.
Special Needs plans
Individuals with certain disabilities are eligible for SN plans. This option customizes benefits, providers, and prescription drug coverage to meet the specific needs associated with each disability.
Most plans require a referral to see a specialist.
A person’s first step in joining an Advantage plan is to use the search tool to see options in their area.
After someone decides on a plan, they can make a direct application to the company. There are several ways to make an application:
- A person may be able to apply online via the company’s website.
- The company must provide a paper enrollment form.
- A person can choose to call the company. The contact information may be found on the company’s website.
A person may also get more information by calling 1-800-MEDICARE (1-800-633-4227).
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Several scenarios may lead to the loss of an Advantage plan. In each situation, a person may join another Advantage plan, although there may be enrollment period restrictions.
If a person does not join a new plan within the specified time frame, they are automatically enrolled in Original Medicare. This action prevents them from being without coverage.
