Do Medicare Advantage Plans Have to Accept Everyone?

Medicare Advantage Plans have become an increasingly popular alternative to Original Medicare. Nearly 30 million Medicare beneficiaries were enrolled in a Medicare Advantage Plan in 2022. But do these private health plans have to accept every Medicare enrollee who applies?

The short answer is yes—with a few exceptions. Medicare Advantage Plans are generally required to accept any eligible Medicare beneficiary who enrolls during established enrollment periods. However, plans also can place some limitations around special needs plans and provider network capacity.

Let’s take a closer look at Medicare Advantage enrollment rules and who these private Medicare Plans must accept.

Medicare Advantage Basics

First, some background on Medicare Advantage. Also known as Medicare Part C, Medicare Advantage Plans are offered by private health insurers as an alternative to Original Medicare (Part A and Part B). These plans must cover all services Part A and B cover, but often include extra benefits like dental, vision and hearing coverage.

Most Medicare Advantage Plans (about 85%) are HMO or PPO plans with provider networks. Some key features:

• Part D Prescription Drug Coverage: Most Medicare Advantage Plans include Part D prescription drug plan. This provides coverage for prescription medications.
• Out-of-Pocket Limits: Medicare Advantage Plans also include or must have an annual limit on your out-of-pocket costs for Part A and B medical services. Original Medicare does not have an out-of-pocket maximum.
• Coordinated Care: Many Medicare Advantage Plans have a primary care provider who helps coordinate your care within the plan’s network.
• Enrollment Periods: You can enroll in Medicare Advantage during your Initial Enrollment Period when first eligible for Medicare, as well as during the Annual Enrollment Period each fall.

Essentially, Medicare Advantage Plans agree to provide all your Part A and Part B benefits in exchange for a monthly premium payment from Medicare. But do they have to accept every Medicare beneficiary?

Medicare Advantage Enrollment Rules

The Centers for Medicare & Medicaid Services (CMS) sets rules that Medicare Advantage Plans must follow around accepting enrollees. Here are some key regulations:

• Open Enrollment: During Initial and Annual Enrollment Periods, Medicare Advantage Plans must accept any eligible Medicare beneficiary who enrolls, with limited exceptions.
• No Denials Based on Health: Medicare Advantage Plans cannot deny enrollment based on your health status or pre-existing conditions.
• No Discrimination: Plans cannot discriminate based on factors like race, gender identity or sexual orientation when accepting enrollees.

So during Medicare’s broad Open Enrollment periods, Medicare Advantage Plans essentially must take all comers, regardless of health status. They cannot pick and choose only healthy applicants.

But Medicare Advantage Plans can place some limitations around plan capacity and special needs status, which we’ll explain next.

Network Capacity Limits Enrollment

While Medicare Advantage Plans must generally accept any eligible enrollee during Open Enrollment, plans can limit enrollment based on provider network capacity.

Each year, Medicare Advantage Plans must submit their projected enrollment numbers to Medicare based on network provider capacity. Once an individual plan hits that pre-approved enrollment limit, they can stop accepting new members.

So network adequacy is one legitimate reason a Medicare Advantage Plan could turn away an applicant even during Open Enrollment. But the plan must have submitted justified enrollment limits ahead of time.

Special Needs Plans Can Limit Eligibility

Special Needs Plans (SNPs) are a specific type of Medicare Advantage Plan designed for people with certain diseases, dual eligibility for Medicare and Medicaid, or low-income status.

SNPs tailor their benefits, provider networks, drug formularies and care coordination to best meet the needs of the specific population they serve. For that reason, SNPs can and do limit enrollment to only individuals meeting the plan’s eligibility requirements.

For example, a Dual Eligible SNP may only accept enrollees who qualify for both Medicare and Medicaid. Or an Institutional SNP might limit membership to provide Medicare beneficiaries living in a nursing home contracted with that MA plan.

So while standard Medicare Advantage Plans must enroll anyone eligible for Medicare, SNPs can limit their membership to those who meet special designation requirements.

Can You Be Disenrolled from a Medicare Health Plan?

For the most part, once you sign up for Medicare Advantage Plan, that plan must continue providing your coverage for the remainder of the calendar year. However, in certain circumstances, an individual can be disenrolled from their Medicare Advantage Plan. Reasons for involuntary disenrollment include:

• Moving out of the plan’s service area
• Losing eligibility for Medicare Parts A and B
• Failing to pay plan premiums for 3 months
• Committing fraud or abuse

If you are disenrolled from your Medicare Advantage Plan, you will return to Original Medicare. You’ll have a Special Enrollment Period to sign up for a stand-alone Part D prescription plan as well.

Switching from Medicare Advantage to Original Medicare

While plans can rarely disenroll you, individuals have broad leeway to voluntarily leave their Medicare Advantage Plan and return to Original Medicare.

The Medicare Advantage Open Enrollment Period from January 1 to March 31 each year allows members to drop their Medicare Advantage Plan, switch to a new plan, or go back to Original Medicare.

You can also switch out of Medicare Advantage and back to Original Medicare during the Annual Enrollment Period each fall.

When you voluntarily return to Original Medicare, you’ll want supplemental coverage through a Medigap or Part D prescription plan. Certain restrictions exist around guaranteed issue rights for Medigap Plans, so it’s wise to carefully consider your decision.

Key Takeaways – Medicare Advantage Enrollment Rules

While Medicare Advantage Plans are required to accept most eligible Medicare beneficiaries who enroll, some limitations exist:

• During Open Enrollment periods, plans must accept applicants unless pre-approved network capacity limits are met.
• Special Needs Plans can limit membership to individuals meeting certain eligibility requirements.
• In rare cases, an individual can be involuntarily disenrolled from a Medicare Advantage Plan due to specific triggering events.
• Members always have the option to voluntarily disenroll from Medicare Advantage and return to Original Medicare during certain windows.

So in summary—yes, Medicare Advantage Plans must generally accept all comers during Open Enrollment each year. But plan network capacity and special plan designations allow some exceptions to this standard enrollment rule.

We’re Here to Help

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FAQS

Do Medicare Advantage Plans have to accept everyone?

A: Medicare Advantage Plans are required to accept everyone who is eligible for Medicare and who resides in the service area of the plan. They cannot deny coverage based on pre-existing conditions or health status.

What are the disadvantages of Medicare Advantage Plans?

Some of the potential disadvantages of Medicare Advantage Plans include limitations on healthcare providers, network restrictions for specialists, the need for referrals to see certain doctors, and the potential for higher out-of-pocket costs.

How can I enroll in a Medicare Advantage Plan?

To enroll in a Medicare Advantage Plan, you must first be eligible for Medicare (typically at age 65 or with certain disabilities) and then you can sign up during the Initial Enrollment Period, the Annual Enrollment Period, or during a Special Enrollment Period if you qualify.

What is a Medicare Supplement Plan?

A: A Medicare Supplement Plan, also known as Medigap, is a type of insurance plan that helps cover the gaps in Medicare coverage. It can help pay for out-of-pocket costs such as deductibles, coinsurance, and copayments.

What are the pros and cons of Medicare?

The pros of Medicare include comprehensive coverage for a wide range of healthcare services and the ability to choose your healthcare providers. The cons include potential gaps in coverage, the need for additional insurance to cover some costs, and potential limitations on healthcare providers.

What are the cons of Medicare Advantage Plans?

Some of the cons of Medicare Advantage Plans include limitations on healthcare providers, network restrictions for specialists, the need for referrals to see certain doctors, and the potential for higher out-of-pocket costs compared to traditional Medicare.

Can I switch back to Original Medicare if I have a Medicare Advantage Plan?

Yes, you can switch back to Original Medicare from a Medicare Advantage Plan during the Medicare Advantage Disenrollment Period, which typically runs from January 1st to February 14th each year.

Are there any Medicare Advantage Plans that require a monthly premium?

Yes, some Medicare Advantage Plans may require a monthly premium in addition to the Medicare Part B premium that you must already pay.

What are the benefits of a Medicare Advantage Plan?

Medicare Advantage Plans offer additional benefits beyond what is covered by Medicare, including prescription drug coverage, vision and dental services, and wellness programs.

Are all Medicare services covered by Medicare Advantage Plans?

Medicare Advantage Plans cover all Medicare services, but they may have different cost-sharing requirements and restrictions compared to Original Medicare. It’s important to review the specific plan details to understand what is covered.