Medicare Fall Open Enrollment Q&A

From our friends at the Medicare Rights Center


Question: Are the dates for open enrollment the same for Medicare and Medicare Advantage?

Answer: The Fall Open Enrollment Period, also known as the Annual Election Period, runs October 15 through December 7 each year. During this time you can switch from Original Medicare to Medicare Advantage, Medicare Advantage to Original Medicare (with or without a stand-alone Part D plan), or you can switch between Medicare Advantage Plans.

 There is also an enrollment period called the Medicare Advantage Open Enrollment Period (MA OEP) which runs January 1 through March 31 each year. During this time, people enrolled in a Medicare Advantage Plan can make one change: they can switch Medicare Advantage Plans or they can switch to Original Medicare (with or without a stand-alone Part D plan). 

Question: If I am dually eligible, or Medi-Medi, can I enroll and disenroll in a Medicare Advantage Plan anytime?

Answer: People who are dually eligible are enrolled in Extra Help, the Medicare drug assistance program. Having Extra Help gives you access to a Special Enrollment Period (SEP) to change your coverage multiple times throughout the year. The Extra Help SEP lets you make a change once per quarter for the first three quarters of the year: January

– March, April – June, and July – September. After the first three quarters of the year, you use Fall Open Enrollment (October 15 to December 7) to make a change.

 Question: I signed up for Medicare for first time on 10/1/2020. Do I have to enroll before 10/1/2021 or can I do it during the Fall Open Enrollment Period?

Answer: Your Medicare coverage continues from year to year. You do not have to sign up again each year, but you should read the Annual Notice of Change that you get from your plan to see if there are any changes for 2022 that do not work for you. If you want to change your coverage for 2022, then you should use the Fall Open Enrollment Period (October 15-December 7) to do so.

Question: I’ve seen commercials that say you can get your premiums paid back. What’s that all about?

Answer: Some plans will provide a give-back of some of your Part B premium. This is taken from the funds that the plan gets from the federal government for handling your coverage. Also, if you qualify for the Medicare Savings Program (MSP), the MSP pays for your Part B premium. Some plans will advertise the MSP as a benefit, though you can get the MSP if you qualify regardless of what type of Medicare coverage you have.

Question: If a doctor is out of network, are the costs typically partially covered by a coinsurance vs. zero coverage?

Answer: How much you owe out-of-network depends on the type of plan you have. In general, if your plan is a Health Maintenance Organization (HMO), you will owe 100% of the cost of services you receive out of network. If your plan is a Preferred Provider Organization (PPO), you may have some coverage for services you receive out-of- network, but you pay more than you would for services received in-network. For example, your PPO may charge a $25 copayment for primary care visits in-network, but a 35% coinsurance for primary care visits out-of-network. Each plan is different, though. If you are interested in learning about a plan’s out-of-network coverage, contact the plan directly.

Question: Can doctors leave a network anytime?

Answer: Yes.

Question: What is the maximum out-of-pocket limit?

Answer: All Medicare Advantage Plans must set an annual limit on your out-of-pocket costs, known as the maximum out-of-pocket (MOOP). This limit is high but it may protect you from excessive costs if you need a lot of care or expensive treatments. After reaching your MOOP, you will not owe cost-sharing for Part A- or Part B-covered services for the remainder of the year. Some plans may also apply the MOOP to supplemental benefits, such as vision, hearing, or dental. 

In 2021, the MOOP for Medicare Advantage Plans is $7,550, but plans may set lower limits. If you are in a plan that covers services you receive from out-of-network providers, such as a PPO, your plan will set two annual limits on your out-of-pocket costs. One limit is for in-network costs and the other is for combined in-network and out- of-network costs.

Question: Can companies charge extra for no-cost preventive care if enrollees have preexisting conditions?

Answer: Original Medicare and Medicare Advantage Plans cannot charge extra for people who have pre-existing conditions.

Question: What is Medicare Part C? Does it include part D? In other words, is Medicare C better than an Advantage plan?

Answer: Medicare Part C is another name for Medicare Advantage Plans. Many Medicare Advantage Plans include drug coverage.


Question: How are the plans rated? I have seen the star rating on the Plan Finder 

Answer: Medicare uses a Star Rating System to measure how well Medicare Advantage and Part D plans perform. Medicare scores how well plans perform in several categories, including quality of care and customer service. Ratings range from one to five stars, with five being the highest and one being the lowest. Plans are rated in each individual category. Medicare also assigns plans one overall star rating to summarize the plan’s performance as a whole. You can use the overall star rating to compare performance among several different plans. To learn more about differences among plans, look at plans’ ratings in each category.

Medicare reviews plan performance yearly and releases new star ratings each fall. This means plan ratings may change from year to year.

Medicare Advantage Plans are rated on how well they perform in five different categories:

1. Staying healthy: screenings, tests, and vaccines

2. Managing chronic (long-term) conditions

3. Plan responsiveness and care

4. Member complaints, problems getting services, and choosing to leave the plan

5. Health plan customer service

Part D plans are rated on how well they perform in four different categories:

1. Drug plan customer service

2.     Member complaints, problems getting services, and choosing to leave the plan

3. Member experience with the drug plan

4. Drug pricing and patient safety

Question: I keep hearing about five-star plans. I have never seen one where I live. 

Answer: Five-star plans may not be available in all areas. You can use Medicare’s Plan Finder or call Medicare at 1-800-MEDICARE (1-800-633-4227) to look up plans in your area and see if any are rated five stars.

Question: Only members of poor performering plans get notice? Where can you see Medicare Advantage Plans with poor performance? I wouldn’t want to accidently change to one.

Answer: Correct: only people already enrolled in a poorly performing plan get a notice. To learn what star rating your plan has, or to check on star ratings on other plans, use the Medicare Plan Finder.


Question: When you sign up for a drug plan, are the prices fixed for the plan year? 

Answer: The premium and deductible stay the same throughout the year, but the costs for individual prescriptions may vary throughout the year.

Question: What happens if in mid-year your doctor wants you to take a medication that is not on the list?

Answer: If there is a specific drug you need to take that is not covered by your plan, and you cannot take any of the alternatives that your plan does cover, then one option is to ask your doctor to help you request a formulary exception. When you request a formulary exception, you are asking your plan to make an exception and cover a drug. Your doctor should provide a letter of support that explains that the other drugs on the formulary do not work for you. Your plan will then make a decision about whether or not to approve your formulary exception request and cover your drug.

Question: Could you clarify what you said about changing Part D and Medicare Advantage Plans until the end of February?

Answer: If your Medicare Advantage or Part D plan is being terminated, you have additional time to make a new plan selection beyond the end of Fall Open Enrollment. If your plan is being terminated, you have up until the last day in February of the following year to choose a new plan. Visit Medicare Interactive to learn about what to do if your plan is ending at the end of the year.

Question: Can you get out of a Part D plan if you do not require prescriptions? 

Answer: You are not required to get a Part D plan, but if you do not enroll in one and you don’t otherwise have creditable drug coverage (drug coverage that is as good as or better than Medicare’s drug coverage), then you will have a late enrollment penalty when you do eventually sign up. The Part D penalty is 1% for each month you delay enrollment. If you do not take any prescriptions, it may make sense to purchase a low- cost Part D plan in order to avoid the late enrollment penalty. You can learn more about the Part D late enrollment penalty on Medicare Interactive. 

Question: What is a transition fill?

Answer: A transition refill, also known as a transition fill, is typically a one-time, 30-day supply of a drug that you were taking:

  • Before switching to a different Part D plan (either stand-alone or through a Medicare Advantage Plan)
  • Or, before your current plan changed its coverage at the start of a new calendar year

Transition refills let you get temporary coverage for drugs that are not on your plan’s formulary or that have certain coverage restrictions (such as prior authorization or step therapy).

Transition refills are not for new prescriptions. You can only get transition fills for drugs you were already taking before switching plans or before your existing plan changed its coverage. You can learn more about transition fills on Medicare Interactive.

 Question: If your plan drops a critical drug, do you get a Special Enrollment Period (SEP)?

Answer: There is no specific SEP for people whose plan drops a drug from its formulary. There are a few different troubleshooting strategies you can try, so please call our helpline at 800-333-4114 to discuss the situation further.

Question: Is the Part D late enrollment penalty (LEP) in perpetuity?

Answer: If you are eligible for Medicare due to age and you have a Part D LEP, you owe the penalty for the rest of your life. If you are eligible for Medicare due to disability and you have a Part D LEP, the LEP goes away when you turn 65.

 Question: Are Part D Plans required to provide individualized drug change coverage to their customers in their ANOC or does the client have to look it up themselves in the new formulary?Answer: Part D plans will send a list of formulary changes in general, so it is up to the enrollee to check the changes and see if any of their drugs have been removed from the formulary.