Medicare Advantage, or Medicare Part C, is an alternative to Original Medicare’s Part A and B hospital and medical insurance. In contrast to Original Medicare that provides the same services to all beneficiaries for a set monthly premium, Medicare Advantage plans are offered by private insurance companies. Most Part C plans provide extra benefits beyond the basic Part A and B services required by Medicare and have varying monthly costs. The additional benefits often included in Medicare Advantage plans are vision, hearing and dental care and prescription drug coverage.
In 2019, approximately 34% of Medicare beneficiaries in the U.S. were enrolled in a Medicare Advantage plan, which was up by 8% from 2018. Nationwide enrollment is expected to reach 50% by 2029, according to research from the Kaiser Family Foundation, but enrollment rates vary from state to state. In Colorado, 38% of Medicare beneficiaries have Medicare Advantage, while the neighboring state of Utah has 35% and Wyoming just 3% enrollment. Alaska has the lowest number of enrollees at 1%, and Hawaii has the highest rate of enrollment at 44%.
There are several types of Medicare Advantage plans, and their availability depends on the insurer and location. In Colorado, seniors can have a choice of HMO, PPO, PFFS or SNP plans. This guide describes each of these Medicare Advantage plans, and provides information about when an individual can enroll and prescription drug coverage. We’ve also included a list of resources that can help Colorado seniors understand their coverage options and how to choose the right plan for their needs.
There are four main types of Medicare Advantage plans available in Colorado, depending on the county: Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) and Special Needs Plans (SNPs).
Health Maintenance Organizations (HMOs)
Health Maintenance Organizations, or HMOs, give plan members access to a network of doctors and medical facilities for their health care services. Enrollees must choose a primary care physician from within the network, and visits to specialists require PCP referrals. These restrictions keep HMO premiums low, and the plans usually have a low or zero deductible. Members who receive services from outside their plan’s provider network may be responsible for the entire cost of care, although out-of-network emergency services may be covered.
Preferred Provider Organizations (PPOs)
PPOs are similar to HMOs in that they have a contract with a network of doctors, hospitals and health care providers who agree on a set fee schedule for the services they provide to members. The main differences with PPOs are that members may choose to see a physician or facility outside of their network at a higher cost, and referrals often aren’t needed to see a specialist. This greater flexibility typically translates to higher premiums, and most PPO plans require that members meet a higher deductible before receiving coverage for their health care costs.
Special Needs Plans (SNPs)
SNPs provide health care coverage for groups of individuals who have specific medical needs. There are three types of SNPs offered in Colorado: Chronic condition SNPs (C-SNP), dual-eligible SNPs (D-SNP) and institutional SNPs (I-SNP). By law, SNPs must include prescription drug coverage so enrollees have consistent access to the medications used to control their conditions. To enroll in an SNP, an individual must qualify for the group the plan serves, be enrolled in Medicare Parts A and B and live in the plan’s service area.
Private Fee-for-Service Plans (PFFS)
Unlike a PPO or HMO, PFFS plans don’t limit enrollees to receiving services from providers within a certain network. Instead, a PFFS plan pays a set amount to individual health care providers for services received by its members. Plan members may choose any physician or medical facility, as long as the provider agrees to accept the plan’s payments terms. There are no requirements to choose a primary care physician, and members may visit specialists without a referral. Not all providers are willing to accept the terms of a PFFS, and premiums are usually higher for these plans.
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.
In Colorado, Medicare Advantage plans that include the cost of prescription medications are called Medicare Advantage prescription drug plans or MA-PDs. To be eligible for enrollment in an MA-PD, an individual must be enrolled in a Medicare Advantage program. These prescription drug plans cover most commonly prescribed medications but don’t cover over-the-counter medications, vitamins or drugs not included on the plan’s formulary list. Some Medicare Advantage plans bundle health and prescription coverage and only charge one monthly premium payment. Other plans require two separate premium payments.
Seniors with Medicare Advantage plans that don’t include prescription coverage may be able to enroll in a stand-alone Medicare Part D plan. Colorado residents can’t enroll in a stand-alone Part D plan while enrolled in an MA-PD plan. Anyone who does risks being dropped from their Medicare Advantage plan and placed back on Original Medicare.
Because there are so many Medicare Advantage plans to choose from, and eligibility and enrollment can be complicated, seniors may need assistance with selecting the right plan and signing up. The following resources in Colorado can provide information and guidance to help seniors find and enroll in a plan that best suits their needs.
The Colorado Division of Insurance participates in the nationwide network of state health insurance assistance programs that provide free counseling to help seniors navigate the complexities of Medicare coverage. The goal of the program is to serve as an advocate and help seniors make the right choices based on their needs. Any state resident who qualifies for Medicare coverage is eligible to receive SHIP counseling. The Division of Insurance website features a convenient link to apply for benefits, along with information about supplemental insurance, Medicare basics and how to report insurance fraud.
Located in Denver, the Colorado Gerontology Society is a nonprofit organization that provides free counseling to Colorado residents on any issue related to Medicare and Medicaid. Counselors can answer questions about coverage options, eligibility and how to apply. The organization’s website also provides a list of community resources for seniors and a calendar of upcoming events.
Centura Senior Links is one of the largest health care networks in Colorado, with more than 21,000 professionals, 17 hospitals and over 100 practices. The network provides counselors who can help seniors understand and apply for Medicare and other health benefit programs. Assistance is available in person for those living in Denver, and by phone for seniors located elsewhere in the state.
For more information about Centura Links and how counselors can help with Medicare and other insurance questions, contact the organization directly at 1-866-550-2752.
The Colorado Foundation for Medical Care is the state health care quality improvement organization. It works hand in hand with Medicare and Medicaid to help improve the quality of health care for seniors and other state residents. The foundation also has a hotline available to seniors who have questions or need help signing up for Medicare.
The Colorado Fund for People with Disabilities (CFPD) helps individuals get the health care they need to maintain their quality of life. Counselors are available to answer questions concerning Medicare, and representative payees are available to make sure insurance bills are paid accurately and on time.
The Pikes Peak Area Agency on Aging provides free information and counseling on Medicare and insurance fraud to seniors who live in El Paso, Park and Teller counties. The agency also offers insurance counseling and access to educational resources by phone in the surrounding counties of Custer, Fremont and Las Animas. The trained staff periodically holds educational classes and gives presentations in the Pikes Peak region to help seniors better understand their Medicare options.
To speak to a counselor or learn when the next presentation is scheduled in your area, contact the agency at 719-471-2096.
The Boulder County Area Agency on Aging serves seniors and adults with disabilities and their families by providing information on elder rights, healthy aging, respite care and Medicare counseling. Seniors may sign up for classes to learn about enrollment, benefits and the costs of Medicare. These classes are held monthly throughout Boulder County.