Medicare Advantage

Medicare Advantage (Part C) plans provide an all-in-one alternative to Original Medicare. These plans must cover all the benefits of Medicare Part A and Part B, and many offer additional features, such as:

Nutrition programs
Fitness memberships
Dental, vision, and hearing care
Prescription drug coverage
Transportation to doctor’s visits

Who Offers Medicare Advantage Plans:

Medicare Advantage plans are provided by private insurance companies that are approved by Medicare. The specific benefits available to you will depend on your plan and your location.

Eligibility for Medicare Advantage:

If you qualify for Medicare Parts A and B, you are eligible to enroll in a Medicare Advantage plan. You must be enrolled in both Part A and Part B to purchase a Medicare Advantage plan, and you cannot opt out of Part B.

When can you enroll in Medicare Advantage

You can join or make changes to a Medicare Advantage plan during specific times. The optimal time to enroll is when you first become eligible for Medicare, typically around your 65th birthday, during your Initial Enrollment Period.

If you already have a Medicare Advantage plan and are dissatisfied with it, you can make changes during the Medicare Advantage Open Enrollment Period, which runs from January 1 to March 31 each year. During this period, you can:

Switch to a different Medicare Advantage plan, with or without prescription drug coverage
Return to Original Medicare and, if needed, enroll in a separate Part D plan

Your new coverage will begin on the first day of the month following your request.

Additionally, you can make changes to your plan during the Annual Open Enrollment Period, which is from October 15 to December 7.

Certain circumstances may also qualify you for a Special Enrollment Period, allowing you to enroll in a Medicare Advantage plan outside the usual enrollment windows.

Medicare Advantage vs Medicare Supplements

Medicare Advantage vs. Medicare Supplements

Both Medicare Advantage and Medicare Supplements offer ways to enhance your Medicare coverage, but you can only choose one or the other. Here’s a comparison to help you determine which might be a better fit for you:

Purpose of These Medicare Plans

Medicare Advantage: This is an all-in-one plan that must cover everything included in Original Medicare (Part A and Part B). Additionally, Medicare Advantage plans often provide extra benefits such as dental, vision, and hearing care. Some plans also offer perks like nutrition programs, gym memberships, and prescription drug coverage.
Medicare Supplements: These plans are designed to help cover out-of-pocket costs that Original Medicare doesn’t fully pay for, such as:
- Part A and Part B coinsurance and copayments
- Part A and B deductibles
- Coverage for the first three pints of blood for transfusions

Medicare Supplements can reduce your out-of-pocket expenses significantly. However, they do not replace Original Medicare; rather, they work alongside it. You cannot use a Medicare Supplement plan without maintaining Original Medicare.

How to Enroll

Medicare Advantage and Medicare Supplement plans each have specific enrollment periods:

Medicare Advantage: You can enroll in a Medicare Advantage plan during your Initial Enrollment Period, which begins three months before your 65th birthday and continues for three months after you turn 65. If you miss this window, you can sign up during the Annual Enrollment Period, which runs from October 15 to December 7 each year. Note that you must be enrolled in Original Medicare before you can enroll in a Medicare Advantage plan.
Medicare Supplements: These plans also require you to be enrolled in Original Medicare first. However, you have a more limited enrollment window. You can apply for a Medicare Supplement plan during the Medigap Open Enrollment Period, which is a six-month period starting the month you are first enrolled in Medicare Part B. After this period ends, it may be more challenging to obtain a Medicare Supplement plan, as you might not have guaranteed issue rights.

Network & Coverage Types

Many Medicare Advantage plans require you to use a specific network of providers, although some may offer out-of-network coverage at a higher cost.

In contrast, Medicare Supplement plans provide coverage at any healthcare facility that accepts Medicare, giving you more flexibility in choosing your providers.

Coverage Types

Medicare Advantage: These plans vary in their structure and benefits. For example:
- A Preferred Provider Organization (PPO) plan typically offers lower costs if you use in-network providers but allows for out-of-network coverage at a higher expense.
- A Private Fee-for-Service (PFFS) plan sets its own payment terms and rates in advance, which can differ from other plans.
Medicare Supplements: There are ten standardized Medicare Supplement plans, labeled Plan A, B, C, D, F, G, K, L, M, and N. These plans differ in the level of coverage they provide, not in how they operate. Medicare Supplements cover costs that Medicare Part A and Part B do not, but only after Original Medicare has paid its share.

Types of Medicare Advantage Plans

Medicare Advantage plans come in various types to meet different health needs. Here are some of the most common plans:

Health Maintenance Organization (HMO) Plan: HMO plans generally require you to use a network of doctors and providers. You usually need a referral from a primary care physician to see a specialist. Out-of-network care typically costs more, if it’s covered at all.
Preferred Provider Organization (PPO) Plan: PPO plans generally do not require referrals from a primary care doctor, and you can see specialists without a referral. You’ll pay less if you use providers within the plan’s network, but you have the option to see out-of-network providers at a higher cost.
Private Fee-for-Service (PFFS) Plan: PFFS plans allow you to visit any Medicare-approved hospital, doctor, or provider that agrees to the plan’s terms and conditions. You are responsible for any costs not covered by the plan.
Special Needs Plan (SNP): SNPs cater to individuals with specific conditions or needs. There are also other Advantage plans such as Medicare Medical Savings Account (MSA) plans and Medicare Advantage plans tailored for veterans. Contact one of our agents to determine your eligibility for these plans.

Costs

Your out-of-pocket costs with Medicare Advantage plans can vary based on several factors, including:

Whether the plan has a monthly premium (some plans may have no premium)
The presence of an annual deductible
Adherence to plan rules, such as using network providers
Copayments for each visit or service
Potential coverage of all or part of your Part B premium
The type and frequency of healthcare services you need
The plan’s annual cap on out-of-pocket costs for all healthcare services

Each Medicare Advantage plan sets its own rates for premiums, deductibles, and other costs, so it’s important to review the details of each plan to understand your potential expenses.

Medicare Advantage HMO Plans

Medicare Advantage plans, offered by private insurance companies, are alternatives to Original Medicare (Part A and Part B). These plans come in various types, including HMOs, PPOs, SNPs, and PFFS. Each type has unique features, so it's essential to compare your options carefully.

HMO Plans (Health Maintenance Organizations)

HMO plans require you to receive care within their network of healthcare providers. If you visit an out-of-network provider, you generally won’t receive coverage for those services, except in emergencies. Here are some key features of HMO plans:

Network Restrictions: To receive coverage, you must use the plan's in-network providers. Out-of-network care is usually not covered, except in emergencies.
Primary Care Doctor: You must select a primary care doctor within the network. To see a specialist, you will need a referral from your primary care doctor.
Enrollment Requirement: You must be enrolled in Original Medicare before you can join an HMO plan.

HMO Plan Coverage

HMO plans cover the same basic services as Original Medicare, including inpatient and outpatient care. They may also offer additional benefits, such as:

Dental coverage
Vision coverage
Hearing coverage
Prescription drug coverage (most HMO plans include this)
Nutrition and wellness programs

The availability of these extra benefits can vary based on your location and the specific plan providers.

Medicare Advantage PPO Plans

Preferred Provider Organization (PPO) plans offer more flexibility compared to Medicare Advantage HMO plans. If you’re enrolled in a PPO plan, you can receive care from any healthcare provider, whether in-network or out-of-network, although using out-of-network providers generally results in higher out-of-pocket costs. Staying within the network will cost you less.

Features of PPO Plans

Freedom of Choice: Unlike HMO plans, PPO plans do not require you to receive care exclusively within their network. You can visit both in-network and out-of-network providers, although out-of-network care will usually cost more.
No Referrals Needed: You do not need a referral to see a specialist. You can see specialists without needing approval from a primary care doctor.
Primary Care Doctor: You are not required to choose a primary care doctor, but if you do, they can be either in-network or out-of-network.

When comparing Medicare Advantage options, particularly HMO and PPO plans, it's essential to understand these differences. Working with an agent from Jersey Medicare Solutions can simplify the comparison process and help you find a plan that best suits your needs.

PPO Plan Coverage

PPO plans provide the same coverage as Original Medicare, including inpatient and outpatient services. Additionally, PPO plans may offer extra benefits such as:

Dental coverage
Vision coverage
Hearing coverage
Prescription drug coverage (most PPO plans include this)
Gym memberships
Nutrition and wellness programs

Keep in mind that the availability of additional benefits varies by location and plan provider.

Medicare Advantage
C-SNP Plans

C-SNPs are Chronic Condition Special Needs Plans. These are a type of Medicare Advantage plan designed specifically for people who have specific chronic conditions. With one of these plans, you have the benefit of access to a network of healthcare professionals who can treat your disease.

C-SNP Coverage

Like other Medicare Advantage (Part C) plans, C-SNPs offer you the same covered services as the hospital and medical insurance under Original Medicare (Part A and Part B). A Medicare Advantage plan can also provide additional benefits such as coverage for dental, vision, hearing, or even gym memberships. Prescription drug coverage comes standard with all C-SNP plans, so you must pay only small copayments instead of the total price for your prescription medications.

Chronic Condition Special Needs Plans contract with a network of healthcare providers who can treat your chronic condition. This often includes specialists in the area of your state, which is one of the main draws of these plans. Under a typical Medicare Advantage plan, you may have had to pay more to see these specialists as they may have been outside the plan’s network.

In an emergency, you can seek treatment from any healthcare provider. If you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis, you can receive these treatments as needed. It would help if you were prepared to pay higher out-of-pocket costs for the care you receive outside your plan’s network.

With a Chronic Condition SNP, you need a primary care doctor or care coordinator who can help manage your healthcare. Having one of these professionals guide your care will ensure you receive the specialized treatments you need.

Qualifying Chronic Conditions For C-SNP Plans

To qualify for a New Jersey C-SNP, you must have a chronic condition defined by Medicare and the Center for Medicare and Medicaid Services (CMS).

The chronic conditions with C-SNP plans include:

Chronic alcohol and other drug dependence
Autoimmune disorders
Cancer, pre-cancer, or in-situ status
Cardiovascular discords
Chronic heart failure
Dementia
Diabetes mellitus
End-stage liver disease
End-stage renal disease (ESRD) requiring dialysis
Severe hematologic disorders
HIV/AIDS
Chronic lung disorders
Chronic and disabling mental health conditions
Neurologic disorders
Stroke

There is also five grouped condition C-SNP plans for the following comorbid chronic conditions:

Diabetes mellitus and chronic heart failure
Chronic heart failure and cardiovascular disorders
Diabetes mellitus and cardiovascular disorders
Diabetes, Mellitus, chronic heart failure, and cardiovascular disorders
Stroke and cardiovascular disorders

Medicare Advantage
D-SNP Plans

Special Needs Plans (SNPs) Overview

Special Needs Plans (SNPs) are a type of Medicare Advantage plan tailored for individuals who meet specific criteria. One common type is the Dual Eligible SNP (D-SNP), designed for individuals eligible for both Medicare and Medicaid. If you qualify for a D-SNP, we can assist you in selecting the right coverage for your needs.

D-SNP Coverage

D-SNPs operate similarly to other Medicare Advantage plans, such as HMOs and PPOs, offering all the coverage provided by Original Medicare (Part A and Part B). In addition to this, D-SNPs include extra benefits, and all SNPs provide prescription drug coverage.

Network and Cost: Most SNPs work with networks of healthcare providers. For D-SNPs, the network is coordinated to include providers who also accept Medicaid, helping to reduce your costs through negotiated lower rates. Using out-of-network providers generally results in higher out-of-pocket expenses.
Emergency Coverage: You are covered for emergency and urgent care services. If you have End-Stage Renal Disease (ESRD) and require dialysis outside your plan’s service area, this will also be covered.
Care Coordination: You will likely be required to select a primary care doctor or care coordinator to help manage your healthcare. Referrals from your primary care doctor are typically needed to see specialists.

Qualifying for a D-SNP Plan

To enroll in a D-SNP, you must be eligible for both Medicare and Medicaid. Eligibility requirements can vary by state, and you must participate in specific Medicaid programs to qualify for these Special Needs Plans.

In New Jersey, Medicaid eligibility is based on income and resource limits. If your income exceeds the limit for a particular Medicaid program, you might be able to "spend down" your income with medical expenses to meet the program’s requirements.

Medicaid Programs in New Jersey include:

Full Medicaid (only)
Qualified Medicare Beneficiary (QMB Only)
QMB Plus
Specified Low-Income Medicare Beneficiary (SLMB Only)
SLMB Plus
Qualifying Individual (QI)

Your eligibility for these programs will determine your options for enrolling in a D-SNP plan. If you need assistance or more information on qualifying, feel free to contact us for help.

Medicare Advantage
PFFS Plans

Medicare Advantage Private Fee-for-Service (PFFS) Plans

Private Fee-for-Service (PFFS) plans are one type of Medicare Advantage plan offered by private insurance companies. Here’s a closer look at the key features, benefits, and potential drawbacks of PFFS plans to help you understand how they work.

Medicare Basics

Before diving into PFFS plans, it’s important to understand the basics of Original Medicare:

Part A: Covers inpatient hospital costs.
Part B: Covers outpatient medical expenses.
Part D: Provides prescription drug coverage through separate Prescription Drug Plans (PDPs).

Medicare Advantage plans, including PFFS plans, are often referred to as “Part C” Medicare Plans and can offer additional benefits beyond Original Medicare.

Medicare Advantage PFFS Plans Explained

Coverage: PFFS plans provide the same coverage as Original Medicare, including hospital and medical services. They may also offer additional benefits such as vision and dental care.
Out-of-Pocket Protection: PFFS plans include a maximum annual out-of-pocket limit, which protects you if you incur significant medical expenses within a year. They also cannot charge more than Original Medicare for many essential services like chemotherapy, radiation, and dialysis.
Cost Structure: Each PFFS plan sets its own payment terms for healthcare services. The amount you pay for care depends on the plan’s predetermined rates. You will continue to pay the standard Medicare Part B premium ($170.10 in 2022) in addition to any premium set by the PFFS plan.
Flexibility and Network: PFFS plans often have networks, but you do not necessarily need to be part of a specific network of providers. You can visit any provider who accepts the plan’s terms. Referrals to specialists are not required, but it’s a good idea to discuss services with your physician to avoid unexpected out-of-pocket costs, as PFFS plans set fees for services in advance.
Prescription Drug Coverage: Many PFFS plans include prescription drug coverage. If your plan does not cover prescriptions, you can add a separate PDP (Prescription Drug Plan) for additional coverage.

For personalized assistance with Medicare Advantage plans, including PFFS plans, contact our experienced Medicare advisors. They can help you find a plan that fits your needs and budget.