Clover Health sells Medicare Advantage plans in Georgia, New Jersey, Pennsylvania, South Carolina, and Texas for the 2026 plan year, offering a mix of $0-premium HMO and PPO options, several plans that reduce your standard Part B premium through a monthly giveback, and bundled Part D prescription drug coverage.1Clover Health. Is Clover in My State? Like every Medicare Advantage plan, Clover’s offerings must cover everything Original Medicare covers, and the company layers on routine dental, vision, and hearing benefits plus an AI tool called the Clover Assistant that participating doctors can use during appointments.2Clover Health. Clover Assistant
Where You Can Get a Clover Plan
Clover operates in five states: Georgia, New Jersey, Pennsylvania, South Carolina, and Texas.1Clover Health. Is Clover in My State? Coverage is not statewide everywhere. Medicare Advantage plans are approved county by county, so a plan available in one part of a state may not be sold in the next county over. Check your specific address against Clover’s service area through the company’s site or on Medicare.gov before you plan around a specific plan.
If you move out of the plan’s service area after enrolling, you get a Special Enrollment Period that lets you switch to another Medicare Advantage plan or return to Original Medicare. That window opens when you move and runs for two full months afterward.3Medicare.gov. Special Enrollment Periods
Who Qualifies
Two requirements, both non-negotiable. You must be entitled to Medicare Part A and enrolled in Part B before you can join any Medicare Advantage plan.4Centers for Medicare & Medicaid Services. Original Medicare (Part A and B) Eligibility and Enrollment And you must live inside the plan’s service area.
People with End-Stage Renal Disease can enroll too. Current rules let ESRD beneficiaries choose between Original Medicare and a Medicare Advantage plan, which was not always the case.5Medicare.gov. End-Stage Renal Disease (ESRD)
HMO or PPO: How the Network Choice Changes Things
Clover offers both HMO and PPO plans, and the structure you pick shapes where you can go for care and how much you pay.
HMO plans are the cheaper structure. You stay inside the plan’s network for routine care; go out of network and the plan does not cover the visit, so you pay the full bill. You also generally need a referral from your primary care physician before seeing a specialist. Emergencies are the exception, covered wherever you are.
PPO plans trade some of that savings for flexibility. You can see any provider who accepts Medicare, in-network or not, and no referral is required for specialists. The catch is cost. Out-of-network co-payments and coinsurance are higher, sometimes substantially. If a specific doctor or hospital matters to you, look them up in Clover’s provider directory or call member services before you enroll.
What You’ll Actually Pay
Medicare Advantage plans must cover every medically necessary service Original Medicare covers.6Office of the Law Revision Counsel. 42 U.S. Code 1395w-22 – Benefits and Beneficiary Protections The cost side is where Clover plans look different from Original Medicare. Rather than Original Medicare’s deductibles and 20% coinsurance on most services, Clover plans mix flat-dollar co-payments, percentage coinsurance, and plan-specific deductibles that vary by plan.
Many Clover plans carry a $0 monthly plan premium. Every member still pays the standard Medicare Part B premium, which is $202.90 per month in 2026.7Centers for Medicare & Medicaid Services. 2026 Medicare Parts A and B Premiums and Deductibles That Part B premium comes out of your Social Security check or is billed to you separately whether the plan premium is zero or not, which is the piece most people miss when they see a $0 plan advertised.
Every Medicare Advantage plan also caps your annual out-of-pocket spending on covered Part A and Part B services. Hit the ceiling and the plan pays 100% of covered services for the rest of the calendar year.8eCFR. 42 CFR 422.101 – Requirements Relating to Basic Benefits For 2026, CMS set the mandatory maximum at $9,250 for in-network services; individual Clover plans may set their caps lower. Original Medicare has no out-of-pocket cap at all, so this is one of Medicare Advantage’s clearest financial protections.
Part B Giveback
Some Clover plans refund part of your Part B premium through a monthly credit, applied to your Social Security check or Medicare bill. For 2026:9Clover Health. Medicare Part B Premium Jumps to $202.90 in 2026
- Georgia: up to $140 per month on the Valor PPO plan.
- New Jersey: $20 to $125 per month depending on the plan, with the Choice Giveback PPO at $110.
- Pennsylvania: $125 per month on the Valor PPO plan.
You have to be paying your own Part B premium to benefit. If Medicaid or a Medicare Savings Program already covers Part B for you, the giveback does not apply. Enrollment in an eligible plan triggers the credit automatically.
How the Plans Rate for 2026
CMS publishes annual star ratings for every Medicare Advantage plan on a one-to-five scale covering clinical outcomes, member satisfaction, and customer service. Higher ratings also bring the plan bonus payments from CMS that can fund richer benefits.10Centers for Medicare & Medicaid Services. 2025 Medicare Advantage and Part D Star Ratings
For the 2026 plan year, CMS gave Clover’s PPO plans 3.5 stars and its HMO plan 4.0 stars.11Clover Health. Clover Health Comments on 2026 Medicare Advantage Star Ratings and Trajectory for Increasing Profitability into 2027 The 4.0 HMO rating is solid. The 3.5 PPO rating is above average but below the 4.0 cutoff that triggers CMS quality bonus payments. If you are weighing Clover’s PPO against competitors, spend a few minutes on Medicare.gov checking whether rival PPO plans in your county hit 4.0 or higher.
When You Can Enroll
You cannot join or switch Medicare Advantage plans whenever you want. Three windows matter.
- Annual Enrollment Period, October 15 through December 7. The main window to join a Clover plan, switch from one Medicare Advantage plan to another, or return to Original Medicare. Changes take effect January 1.12Medicare. Open Enrollment
- Medicare Advantage Open Enrollment Period, January 1 through March 31. Available only if you already have a Medicare Advantage plan. You get one switch to a different plan or back to Original Medicare, effective the first of the month after Clover receives your request.13Medicare. Joining a Plan
- Special Enrollment Periods, triggered by qualifying life events such as moving out of your service area, losing other coverage, or qualifying for Medicaid. The length depends on the event.3Medicare.gov. Special Enrollment Periods
You can apply through Medicare.gov, on Clover’s website, by phone, or by mailing a paper form. Once your new enrollment is processed, your previous Medicare Advantage or Part D plan is cancelled automatically. You do not need to contact the old plan to disenroll.
If Clover Denies a Claim
If Clover denies coverage for a service, refuses to pay a bill for care you received, or stops covering a treatment you believe you still need, you have the right to appeal. The plan has to tell you about any denial in writing and explain how to challenge it.14Medicare.gov. Filing an Appeal
Medicare Advantage appeals move through five levels. If Clover upholds its denial at the first level, the case goes to an independent review organization, then to an administrative law judge, and on up from there. Each level is a fresh look by a different decision-maker, so an initial no is not the end. Deadlines and procedures are spelled out in your plan materials and on Medicare’s website. The appeals process is federal law, not a courtesy from the plan, so use it when a decision looks wrong.