Page Reviewed / Updated - May 13, 2020
Through Medicare Advantage, seniors eligible for Medicare can enroll in a more comprehensive, private health plan of their choosing. In each state, Medicare provides funding to private health insurance companies offering Medicare-approved plans. Also known as Medicare Part C, Medicare Advantage includes the hospital and medical benefits of Medicare Parts A and B but can provide additional coverage, such as vision, dental and prescription drugs. Unlike Original Medicare, where all enrollees receive the same coverage, Medicare Advantage participants can obtain varying benefits through a choice of plans with differing costs, coverage levels and rules.
According to the Kaiser Family Foundation's 2019 data, in Alabama, the percentage of Medicare-enrolled seniors participating in Medicare Advantage is 39%. This is higher than the national average of 34% and higher than the level of participation of neighboring states. Medicare Advantage enrollment levels are only slightly lower in Georgia and Tennessee, but they're significantly lower in Mississippi, where participation is only 18%. Within the Southeast, only Florida has a higher rate of enrollment than Alabama at 43%.
Senior residents of Alabama who are interested in enrolling in Medicare Advantage can choose from numerous health insurance companies and plan types that include PPOs, HMOs and PFFS. Because sifting through the many options and understanding the differences between plan types can be a time-consuming challenge, we've created this concise yet detailed guide to inform seniors of Alabama's Medicare Advantage plan types. We also discuss when and how seniors can enroll. Additionally, we explain how seniors can receive prescription drug coverage and include several resources available within the state that can help seniors find the best plan for their needs and budget.
Alabama offers three general Medicare Advantage plan types: Preferred Provider Organization (PPO), Health Maintenance Organization (HMO) and Private Fee-for-Service (PFFS).
Health Maintenance Organizations (HMO)
Health Maintenance Organizations, or HMOs, are a type of health insurance plan that includes a network of approved providers. HMOs are typically the most affordable option, with lower premiums and out-of-pocket limits on average for in-network services than other types of plans. To obtain the plan's benefits at the lowest cost, however, participants must receive services only from providers on the in-network list — often only with the exception of emergency room and out-of-town urgent care — and adhere to certain other restrictions. Usually, participants must choose a primary care doctor for the most basic medical needs and request and receive a referral from this doctor before visiting a specialist.
Preferred Provider Organizations (PPO)
Preferred Provider Organizations, or PPOs, are plan types that often offer participants more flexibility but at a higher cost. Like HMOs, PPOs have a network of preferred providers from which participants can receive their benefits at the plan's lowest prices. However, participants can also obtain some coverage of costs if they choose to visit an out-of-network provider. Additionally, participants of PPOs don't need to select a primary care doctor or receive a referral for specialist visits.
Private Fee-For-Service (PFFS)
With the rarer Private Fee-For-Service, or PFFS, plan type, carriers decide how much they will pay health care providers and hospitals for services and how much participants must pay. To receive coverage, participants must make sure the provider they visit agrees to the rates set by the plan. Some plans have a list of preferred, in-network providers, and some don't. For those plans with a network, costs are typically lower when participants stay in the network, but they can still opt to visit out-of-network providers. Some plans cover prescription drugs, and participants may enroll in a separate prescription drug plan if their PFFS plan doesn't include it. These plans typically offer seniors more flexibility because they don't require participants to choose a primary care doctor or receive referrals from specialists. Also, participants can often decide where and from whom they obtain care as long as the providers they pick agree to treat them and agree to the plan's terms.
Prior to enrolling in Medicare Advantage, seniors must first be enrolled in Original Medicare. Anyone who is eligible for Medicare Parts A and B is also eligible to enroll in Medicare Advantage. However, certain Medicare Advantage plans, such as SNPs, may have additional eligibility requirements.
Medicare Advantage has specific enrollment periods. One can only join a Medicare Advantage plan during the following periods:
Additionally, Medicare Advantage plan participants can change their plan outside of these enrollment periods under certain qualifying circumstances, such as moving to a new state.
Most of Alabama's Medicare Advantage HMO and PPO plans include prescription drug coverage through what's known as an MA-PD plan. This means that many Alabama seniors enrolled in Medicare Advantage don't need to enroll in Medicare Part D or a stand-alone prescription drug plan. In fact, seniors who do choose to participate in an HMO or PPO plan must enroll in an MA-PD if they wish to receive coverage for prescription drugs because they may not enroll in both Medicare Advantage and Medicare Part D. PFFS plans are an exception. They may allow seniors to obtain prescription drug coverage directly through their health plan or enroll in Medicare Part D if the PFFS plan doesn't offer coverage.
Navigating the many intricacies of Medicare Advantage plan types, insurance companies available by region and the specific plans they offer can be a difficult and time-consuming task. While the ability to select a specific plan can be a great advantage to a senior who desires comprehensive coverage and more control over their health care, it can be a challenge to find and understand the best plan for their unique needs. Fortunately, Alabama offers several resources locally and throughout the state that seniors can contact for Medicare-related help. Below, we've listed organizations and programs along with a brief description of their services and their contact information.
Through Alabama's State Health Insurance Assistance Program, volunteers and counselors help seniors select the best Medicare health insurance and prescription drug plans for their needs. Advisers can explain the specific benefits available to seniors within their region, answer questions and help seniors file claims and appeals. Along with providing information on Medicare options, volunteers and counselors are knowledgeable about long-term care options, home health care services and Medigap. Because they're not tied to any one insurance company, they can provide unbiased information and guide seniors to more resources. Counseling sessions are confidential, and counselors may also give informative presentations to groups upon request.
Alabama seniors can reach SHIP counselors and volunteers by calling 1-800-AGELINE (1-800-243-5463), where they're directed to their local Area Agency on Aging and their Aging and Disability Resource Center.
KEPRO is Medicare's Beneficiary and Family-Centered Care Quality Improvement Organization. Alabama Medicare beneficiaries can contact KEPRO or visit its website if they need to file a complaint or appeal their Medicare services or coverage. Through its Immediate Advocacy program, KEPRO representatives, including social workers, can contact Medicare providers and facilities directly to help quickly resolve a senior beneficiary's complaint or concern. This can mean helping a senior schedule a doctor's appointment or better understand their treatment plan. KEPRO has a help line dedicated to beneficiaries, and its website lists additional resources Alabama seniors can access for aging-related services, filing complaints against health care facilities and providers, potential Medicare fraud and insurance counseling.
Seniors can call KEPRO toll-free at 888-317-0751 or dial the local number at 813-280-8256. They can also send communication to KEPRO's mailing address at 5201 West Kennedy Boulevard, Suite 900, Tampa, FL 33609.
The Alabama Department of Senior Services, also known as Alabama Ageline, provides seniors with a useful website outlining information on the state's many senior services and senior programs. The department oversees Alabama's Area Agencies on Aging and ADRCs, and its website includes information on upcoming events such as senior caregiver workshops and brochures on SHIP, Alabama Cares and SenioRX programs. The site also contains information on programs that help seniors with disaster preparedness, employment training and obtaining legal services.
Individuals can contact the Alabama Department of Senior Services by calling 1-800-AGELINE (1-800-243-5463), emailing [email protected] or visiting the office at 201 Monroe Street, Suite 350, Montgomery, AL 36104.
Area Agencies on Aging are organizations spread throughout Alabama that serve seniors in specific counties. They provide free Medicare counseling through Alabama's SHIP program and also offer related services such as educational presentations and prescription assistance to help seniors receive their medications for free or at a low cost. They also provide Aging and Disability Resource Centers that offer seniors and their loved ones a wealth of information on aging and health care resources and benefits available throughout the state.
A full list of Alabama's Area Agencies on Aging, their contact information and counties served can be found on the West Alabama Aging website here.
The Central Alabama Aging Consortium provides home- and community-based services to eligible seniors and their loved ones in Montgomery, Autauga and Elmore counties. The Consortium's Aging and Disability Resource Center assists seniors in learning about and understanding benefits they may be eligible for throughout the state. Seniors can also connect with SHIP volunteers to learn about their Medicare options and long-term insurance. Other services include nutrition counseling and a Care Transitions program to help seniors adjust as they move back home from an institution or hospital.
Local seniors can call 334-240-4670 to reach the ADRC or call the main line at 334-240-4680. They may also visit the Central Alabama Aging Consortium in person at 2500 Fairlane Drive, Suite 200, Montgomery, AL 36116 or email [email protected].