Medicare Advantage is a type of private health insurance that includes all the benefits of Medicare Parts A and B. Also referred to as Medicare Part C, or MA, Medicare Advantage plans are government-approved alternatives to Original Medicare, and some of these plans may include prescription drug coverage. Costs, co-pays and exclusions vary between MA plans, and plan availability is location-dependent. Some Medicare Advantage plans include additional benefits that aren’t offered under Original Medicare, such as vision and dental care, transportation and adjunct medical services.
Medicare Advantage insurance is growing in popularity, and the Kaiser Family Foundation reports that about 36% of eligible Americans are enrolled in a private MA plan. Within Arizona, MA enrollment rates vary from a high of 49% in Santa Cruz County, to a low of 7% in Apache County. Statewide, Arizona Medical Advantage enrollment is slightly higher than the national average at 39%, which is similar to enrollment rates in neighboring California (40%), Nevada (36%) and Utah (36%). The highest MA enrollment rates are in Hawaii (44%), Puerto Rico (70%) and Florida (43%), while only 3% of eligible seniors have Medicare Advantage in Wyoming. Overall, the nationwide adoption rate for MA has risen by 10% between 2010 and 2020.
Seniors in Arizona who want to purchase a Medicare Advantage plan have dozens of unique plans and providers to choose from. HMO, PPO and PFFS plans are available to all seniors, while D-SNPs are available to those who meet specific enrollment criteria. This guide is intended to provide an overview of the types of plans offered in Arizona and detailed information on MA enrollment. We’ve also compiled a list of statewide and local resources that seniors, caregivers and family members can use to navigate their Medicare Advantage options.
There are four types of Medicare Advantage plans available in Arizona, including Health Maintenance Organization (HMO) plans, Private-Fee-For-Service (PFFS) plans and Preferred Provider Organization (PPO) plans. There is also a Special Needs Plan (SNP), also known as a Dual Special Needs Plan (D-SNP), that has specific eligibility criteria.
Health Maintenance Organizations (HMO)
Health Maintenance Organizations are groups of medical providers that deliver services to plan members at a fixed cost. HMOs usually offer the lowest priced Medicare Advantage plans. However, in order to control costs, HMOs will only cover care provided through in-network doctors and affiliated professionals. HMOs also limit access to specialists by requiring a referral through a primary care physician.
Private Fee-For-Service (PFFS)
Private Fee-For-Service or PFFS plans are private insurance plans that allow members to seek care from any doctor, hospital or provider. The insurance company determines the cost of services, and in-network costs are generally lower than the cost of seeing an out-of-network doctor. With a PFFS plan, patients are not required to choose a primary care physician, and members can self-refer to a specialist. Some PFFS plans include prescription drug coverage.
Preferred Provider Organizations (PPOs)
As with PFFS and HMO plans, PPO Medicare Advantage plan members need to see an in-network provider in order to pay the lowest available co-pays. What sets PPOs apart from HMOs is that PPO members can seek care from out-of-network doctors, therapists and services and still have a portion of these costs covered. PPO members can usually self-refer to specialists.
Dual Special Needs Plans (D-SNPs)
Dual Special Needs Plans, or D-SNPs, are HMO plans available to those who qualify for both Medicare and Medicaid, as well as those who are institutionalized and/or have specific chronic disabilities or diseases. D-SNPs are designed to improve service delivery and reduce costs, and by law, all D-SNPs must include prescription drug coverage.
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.
With the exception of D-SNPs, prescription drug coverage is not automatically included in Arizona Medical Advantage plans. Seniors who require prescription drug coverage will need to either purchase a plan that includes this benefit or pay for a separate Medicare Prescription Drug Plan.
Finding the right Medicare Advantage plan in Arizona can be challenging. There are dozens of plans to choose from, and plan availability varies between counties. Plan coverage, benefits and costs also differ with the location and each provider. To help older adults navigate the various Medical Advantage plans, we’ve prepared a list of free and low-cost Medicare Advantage resources available to seniors, their family members and caregivers.
Arizona’s DES Division of Aging and Adult Services administers the State Health Insurance Assistance Program, a free Medicare counseling program. Also known as SHIP, this program aims to educate and empower Medicare-eligible adults and their families by providing unbiased information about Medicare Advantage plans, benefits and costs. SHIP is delivered through a network of trained and vetted volunteer counselors who provide one-on-one counseling sessions, both in-person and over the phone. SHIP counselors are located throughout the state, and most are based in local senior centers and nonprofit organizations.
To find a local SHIP counselor, seniors can call the statewide toll-free SHIP hotline at 1-800-432-4040 or visit their nearest seniors’ center.
Established in accordance with the federal Older Americans Act, Arizona’s Legal Assistance Program provides seniors aged 60 and older with legal information, advice and advocacy related to civil matters, such as health care, guardianship and estate planning. The program aims to help seniors maintain their independence and financial security by ensuring older adults have access to free and low-cost legal assistance.
Arizona’s Senior Medicare Patrol program works to protect Medicare beneficiaries against fraud, abuse and billing errors. Professionally-trained SMP staff and screened volunteers provide seniors with information about Medicare scams, such as illegal marketing, double-billing, identity theft and claims for unnecessary services. SMP workers host free community seminars, answer calls and emails from Medicare members and meet with seniors on a one-to-one basis to review complaints and concerns related to Medicare. If illegal activity is suspected, SMP will escalate complaints to the appropriate authorities.
To contact the Arizona Senior Medicare Patrol, seniors can call the SMP Helpline at 1-800-432-4040.
The Arizona Association of Area Agencies on Aging is a network of seven regional agencies that work to create and maintain resources for older adults. These agencies are located throughout the state and are actively involved in elder advocacy at the local, state and federal level. The focus of these AAAs is to improve access to services designed to help seniors maintain their dignity, independence and community involvement.
Arizona seniors who live with physical, psychiatric, cognitive, sensory or mental disabilities who require legal support with disability-related issues can contact the Arizona Center for Disability Law. The ACDL is a nonprofit, public interest law firm that provides a range of legal services including education, advocacy and representation. ACDL has a series of free self-advocacy guides that include plain language advice on managing dual insurance coverage, such as Medicare Advantage Dual Special Needs Plans.
The Pima Council on Aging is a nonprofit organization that provides free and low-cost programs for seniors in Pima County. The Council maintains an online database of current resources for older adults, and certified information and referral specialists are available to help seniors connect with community supports. Seniors and their family members can enroll in a free two-hour Understanding Medicare presentation that provides an overview of Medicare benefits and plans, including Medicare Advantage plans. The presentation is followed by a one-hour Q&A session, and one-on-one Medicare counselors are available to meet with seniors who need more information about Medicare Advantage.
The City of Phoenix operates 15 senior centers that provide low-cost and free programming and services designed to help older adults remain active in their communities. In addition to offering a variety of social and recreational opportunities, these centers host nutrition programs and health screening clinics for seniors. Centers also provide one-on-one case management services to seniors that may include help with Medicare Advantage plans, rental assistance and referrals to area resources.