Ambetter is a private Medicare Advantage plan, not traditional Medicare

Ambetter offers Medicare Advantage plans — also called Part C plans — sold by Ambetter Health, a subsidiary of Centene Corporation. These are private insurance plans that contract with Medicare to cover the same services as Original Medicare (Part A and Part B), but often with different costs, provider networks, and extra benefits.

Ambetter Medicare Advantage plans are available in select states and counties. You must be enrolled in Medicare Parts A and B to join an Ambetter plan, and you pay a monthly premium to Ambetter in addition to your Medicare Part B premium to the government. Ambetter plans typically include prescription drug coverage (Part D) built in, so you do not buy a separate drug plan.

The main trade-off with any Medicare Advantage plan, including Ambetter, is that you use doctors and hospitals in Ambetter's network. If you go out of network (except in emergencies), you may pay more or the plan may not cover the visit at all. Original Medicare has no network restrictions — you can see any doctor who accepts Medicare.

Key Takeaways

  • Ambetter Medicare Advantage plans are private insurance alternatives to Original Medicare, available only in certain states and counties.
  • You must already have Medicare Parts A and B to enroll in an Ambetter plan, and you will pay a separate monthly premium to Ambetter.
  • Ambetter plans include prescription drug coverage and often offer extra benefits like dental or vision, but require you to use in-network doctors and hospitals.
  • You can only join or switch Ambetter plans during the Annual Enrollment Period (October 15 to December 7) or if you have a may have access to life event.

How Ambetter Medicare Advantage plans differ from Original Medicare

Original Medicare is run by the federal government and covers hospital care (Part A) and doctor visits (Part B) with no network — you can see any provider who accepts Medicare anywhere in the country. You pay a deductible and coinsurance for each service. Prescription drugs are covered separately under Part D, which you buy from a private insurer.

Ambetter Medicare Advantage plans bundle hospital, doctor, and drug coverage into one plan sold by a private company. Instead of paying per service, you typically pay a copay or coinsurance when you see a doctor or fill a prescription. Many Ambetter plans charge $0 monthly premium, though you still pay your Part B premium to Medicare. The trade-off is that you must use Ambetter's network of doctors and hospitals, and you may need a referral to see a specialist.

Ambetter plans often include benefits Original Medicare does not cover, such as dental cleanings, vision exams, hearing aids, or fitness programs. However, these extras vary by plan and by state. You should compare what each Ambetter plan in your area actually covers before enrolling.

What to know about Ambetter's provider network and costs

Each Ambetter plan has its own network of doctors, hospitals, and pharmacies. Before you enroll, you should check whether your current doctors and preferred hospital are in the Ambetter network you are considering. Ambetter's website and plan documents list in-network providers by location.

If you see an out-of-network doctor or go to an out-of-network hospital (except in true emergencies), you will pay more out of pocket, or the plan may not cover the visit at all. Some Ambetter plans offer limited out-of-network coverage, but this varies. Emergency care is covered in-network rates even if you go to an out-of-network hospital.

Costs in an Ambetter plan include a monthly premium (often $0, but varies by plan and state), a yearly deductible (the amount you pay before the plan starts to help), copays for doctor visits and prescriptions, and coinsurance (a percentage of the cost you pay after you meet your deductible). These costs differ from plan to plan. You should review the Summary of Benefits and Coverage document for any plan you are considering to understand the exact costs.

When you can enroll in or change an Ambetter plan

You can enroll in an Ambetter Medicare Advantage plan or switch to a different plan only during specific times of year. The main enrollment window is the Annual Enrollment Period, which runs from October 15 to December 7 each year. Coverage begins January 1 of the following year.

If you have a may have access to life event — such as moving to a new state or county, losing other health coverage, or getting married — you may be able to enroll or switch plans outside the Annual Enrollment Period. You typically have 60 days from the event to make a change. Ambetter or Medicare can tell you whether your situation qualifies.

If you are new to Medicare, you have a 7-month Initial Enrollment Period centered on your 65th birthday month. During this window, you can enroll in an Ambetter plan without waiting for the Annual Enrollment Period.

Prescription drug coverage in Ambetter plans

Ambetter Medicare Advantage plans include prescription drug coverage (Part D) as part of the plan. You do not buy a separate Part D plan from another company. When you fill a prescription at an in-network pharmacy, you pay a copay or coinsurance based on the drug's tier in Ambetter's formulary.

Each Ambetter plan has a formulary — a list of covered drugs organized by tier. Tier 1 drugs (usually generics) have the lowest copay. Tier 2, 3, and 4 drugs cost more. Some drugs may not be on the formulary at all, meaning Ambetter will not cover them. If your current medications are not covered, you should ask Ambetter about alternatives or request an exception before you enroll.

Like all Medicare Part D plans, Ambetter plans have an annual out-of-pocket limit. Once you reach this limit in a calendar year, the plan covers most remaining drug costs. The limit changes each year.

How to learn about Ambetter plans are available in your area

Ambetter Medicare Advantage plans are not available everywhere. Availability depends on your state and county. To find out whether Ambetter offers plans where you live, you can visit Medicare.gov and use the plan finder tool, or you can call Medicare at 1-800-MEDICARE (1-800-633-4227).

You can also visit Ambetter's website directly and enter your zip code to see which plans are sold in your area. If Ambetter does not offer plans in your county, you can compare other Medicare Advantage plans or consider staying with Original Medicare and buying a separate Part D drug plan and Medigap supplemental insurance.

Questions to ask before choosing an Ambetter plan

Before you enroll in any Ambetter plan, gather information about your health care needs and compare it to what the plan covers. Ask yourself: Are my doctors in the network? Does the plan cover my prescriptions? What are the copays and deductibles? Do I need the extra benefits like dental or vision?

You can call Ambetter directly to ask questions about a specific plan, or you can speak with a counselor at your State Health Insurance information Program (SHIP). SHIP counselors are free and unbiased — they do not work for insurance companies. To find your SHIP, visit shiptalk.org or call 1-877-839-2675.

Frequently Asked Questions

Can I switch from Ambetter to Original Medicare if I change my mind?

Yes. If you enroll in an Ambetter plan and later decide you prefer Original Medicare, you can switch during the Annual Enrollment Period (October 15 to December 7). You can also switch if you have a may have access to life event. Once you switch back to Original Medicare, you will need to buy a separate Part D drug plan and may want to buy Medigap supplemental insurance.

Do I still pay my Medicare Part B premium if I have an Ambetter plan?

Yes. You pay your regular Medicare Part B premium to the federal government, plus any monthly premium charged by Ambetter (which may be $0). The Ambetter premium is separate from your Part B premium. If you receive Social Security, your Part B premium is usually deducted automatically.

What happens if I move to a state where Ambetter does not have plans?

If you move out of the service area where your Ambetter plan operates, you have a 60-day window to enroll in a different Medicare plan. You can choose another Medicare Advantage plan in your new area, switch to Original Medicare, or both. Contact Ambetter or Medicare to report your move and learn your options.

Are there limits on how many times I can switch plans?

You can change Medicare Advantage plans once per year during the Annual Enrollment Period. If you have a may have access to life event (like moving or losing coverage), you may be able to switch outside this window. Once you switch, you cannot switch again until the next Annual Enrollment Period unless another may have access to event occurs.

How do I know if Ambetter's drug formulary covers my medications?

You can search Ambetter's formulary on their website by entering your medications and zip code. If a drug is not covered or is in a high tier, you can ask Ambetter for a formulary exception before you enroll. Your doctor can also request an exception after you join the plan if your medication is not covered.