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Nov 16, 20235 min read

Do Medicare Advantage Plans Have to Accept Everyone? Pros and Cons of Medicare Advantage Plans

Updated: Oct 10

Medicare Advantage Plans are required to accept any Medicare beneficiary who applies during approved enrollment periods. They cannot deny membership based on pre-existing conditions or other discriminatory reasons. However, Medicare Advantage Plans can disenroll members under certain circumstances allowed by Medicare rules.

Must Medicare Advantage Plans Enroll All Applicants?

Yes, Medicare Advantage Plans operated by private insurers must accept any eligible Medicare beneficiary who enrolls during initial enrollment at 65 or general enrollment periods:

Medicare Advantage Plans often cannot refuse enrollment to anyone with Medicare Part A and Part B coverage based on pre-existing medical conditions, health status or claims history.

Plans also cannot deny membership applications or coverage for discriminatory reasons such as disability, chronic illness, race, religion, gender or sexual orientation.

The only reasons a Medicare Advantage Plan can reject an enrollment application are failure to pay premiums or loss of Medicare Part A/Part B eligibility.

During approved enrollment periods like open enrollment between January 1 and March 31 each year, Medicare Advantage Plans must accept all Medicare beneficiaries who apply without restriction.

Are There Exceptions to Medicare Advantage Acceptance Rules?

There are a couple special scenarios where Medicare Advantage Plans can limit new member acceptance:

Medicare Special Needs Plans (SNPs) - These plans serve specific populations, like people with certain disabilities or chronic conditions. SNPs must only accept members meeting eligibility requirements.

Capacity Limits - Medicare Advantage Plans can set limits on maximum membership capacity. If an SNP or plan reaches capacity, it can stop accepting new members until space opens up again.

Service Area Restrictions - Medicare Advantage Plans are regional and just cover a specific service area. If you move out of that area, the plan will terminate your membership.

Can Medicare Advantage Plans Drop Members?

While Medicare Advantage Plans must accept any eligible applicant, they can involuntarily disenroll members under certain circumstances:

Loss of Medicare Part A/Part B - Members who lose Medicare coverage eligibility can be dropped from their Medicare Advantage Plan.

Failure to Pay Premiums - After a grace period, Medicare Advantage Plans can disenroll members for failure to pay monthly plan premiums.

Moving Out of the Service Area - Medicare Advantage Plans are regional, so members who move out of the plan's service area can be involuntarily disenrolled.

Fraud or Abuse - In rare cases of fraud, misrepresentation or abuse by a member, a Medicare Advantage Plan may drop the member.

Threats to Providers or Members - Disruptive or threatening behavior toward providers, staff or other plan members can lead to involuntary disenrollment.

Improper Use of Benefits - Inappropriate use of plan membership cards or intentional misuse of benefits not in line with plan rules can prompt disenrollment.

Do Medicare Advantage Plans Have Capacity Restrictions VS Original Medicare

While required to accept new members during open enrollment periods, Medicare Advantage Plans can apply for Medicare approval to limit membership:

Medicare Advantage Plans can demonstrate a need to limit acceptance only to a set maximum number of members each year due to capacity constraints.

Once the Medicare Advantage Plan reaches the approved limit, it can stop accepting new members until space opens back up.

Members who enroll while capacity is reached are put on a waiting list in the order applications are received. Open slots are filled from the waitlist.

Capacity restrictions cannot be used to discriminate or cherry-pick only healthy members. Limits must apply evenly once the maximum is reached.

Can You Appeal Involuntary Disenrollment from a Medicare Advantage Plan?

Yes, members have guaranteed appeal rights if involuntarily disenrolled from their Medicare Advantage Plan:

You can request a hearing and formal appeal of the disenrollment decision within 60 days of the notice.

If coverage was terminated in error or in violation of Medicare Advantage enrollment and disenrollment rules, the termination can be overturned through appeal.

During the appeals process, you may be able to remain enrolled in your Medicare Advantage Plan if you continue paying premiums.

If your appeal is unsuccessful, your Medicare Advantage coverage will end and you will switch back to Original Medicare.

While Medicare Advantage Plans cannot cherry-pick members, they do not have to keep members who violate rules or eligibility. But involuntary disenrollment can be appealed.

FAQs

Do Medicare Advantage Plans have to accept everyone?

Medicare Advantage Plans cannot deny coverage to anyone based on pre-existing conditions, but they may have certain eligibility requirements. It's important to check with individual plans for specific enrollment criteria.

What are the pros and cons of Medicare?

Medicare provides comprehensive health coverage for individuals aged 65 and older, or those with certain disabilities. Pros include extensive coverage and various plan options. Cons may include out-of-pocket costs and coverage limitations for certain services.

What are the disadvantages of Medicare Advantage Plans?

The disadvantages of Medicare Advantage Plans may include limited provider networks, potential out-of-pocket costs, and the need for referrals to see specialists. However, they also offer additional benefits not provided by Original Medicare.

Can I switch back to Original Medicare if I don't like my Medicare Advantage Plan?

Yes, you can switch back to traditional Medicare during the annual enrollment period or during special enrollment periods under certain circumstances. Be sure to compare the coverage options before making a decision.

Why do some doctors not like Medicare Advantage?

Some doctors may have concerns about reimbursement rates and administrative complexities associated with Medicare Advantage Plans. However, many providers participate in these plans to expand their patient base.

Can I enroll in a Medicare Advantage Plan if I already have a Medicare Supplemental insurance plan (Medigap Plan)?

No, you cannot have both a Medigap Plan and a Medicare Advantage Plan at the same time. You must disenroll from the Medicare Supplement, Medigap Plan before enrolling in a Medicare Advantage Plan.

What are the cons of Medicare Advantage Plans?

The cons of Medicare Advantage enrollees plans may include limitations on out-of-network coverage, potential network restrictions, and the need to follow plan rules for obtaining services. It's important to review these limitations when considering enrollment.

Are there many Medicare Advantage Plans available in my area?

The availability of Medicare Advantage Plans may vary by location. Some areas may have a wide selection of plans to choose from, while others may have fewer options. It's important to research the available plans in your specific area.

What is the difference between Medicare Part A and Part B?

Medicare Part A provides coverage for inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care. Medicare Part B covers medically necessary services like doctor's visits, outpatient care, and preventive services.

What are the options if I want to return to Original Medicare from a Medicare Advantage Plan?

If you wish to switch back to Original Medicare Plan, you can do so during the annual enrollment period or during a special enrollment period. It's important to compare coverage options and potential costs before making the switch.