Page Reviewed / Updated - May 18, 2020
Medicare Advantage is also known as Medicare Part C. It’s an all-in-one Medicare program that includes the hospital and medical insurance covered in Original Medicare Parts A and B. Medicare Advantage plans are provided by private companies and usually include extra benefits not offered by Original Medicare, such as vision, dental and prescription drugs. Medicare Advantage plans have varying costs and coverage levels, but the out-of-pocket costs are often lower than Original Medicare. Most Medicare Advantage plans do require that enrollees use in-network health care professionals.
Nationwide, 34% of Medicare beneficiaries are enrolled in a Medicare Advantage plan; however, the popularity varies from state to state. At 39%, Connecticut has one of the higher rates of enrollment in the country, and the highest in New England. Neighboring Massachusetts has an enrollment rate of 22%, while Vermont and New Hampshire are lower again at 11% and 17%, respectively. There are seven states with higher enrollment numbers than Connecticut, including Pennsylvania at 41%, and Hawaii, which has the highest rate at 44%.
There are a variety of plans and providers available to seniors interested in Medicare Advantage in Connecticut. The majority of Connecticut seniors enroll in HMO plans, but PPO, SNP and other plans are also available, some of which include prescription drug coverage. This guide explains the different types of plans available, prescription drug coverage for Medicare Advantage enrollees in Connecticut, and when seniors can enroll in Medicare Advantage. There’s also information about available resources for Connecticut seniors who feel they need more help to determine the right Medicare Advantage plan for them.
Medicare Advantage offers enrollees several different types of plans. In Connecticut, there are four plan types available: Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-For-Service (PFFS) and Special Needs Plans (SNPs).
Health Maintenance Organizations (HMO)
Health Maintenance Organizations, or HMOs, tend to have lower premiums than other Medicare Advantage plans, which can make them appealing to seniors. However, the care options for plan members are limited. HMOs have a network of doctors and other health care providers, and plan participants must get care from these in-network providers to have any portion of their costs covered. If out-of-network care is received, the plan member may have to pay the entire cost. Most HMOs require that plan participants select a primary care physician, and patients typically need a referral to see a specialist.
Preferred Provider Organizations (PPO)
Preferred Provider Organizations, or PPOs, also use a network of providers, made up of doctors, facilities, pharmacists and others who have agreed to participate in the plan network. There are local PPOs that have a network centered on a county or state, and regional PPOs with networks that cover multiple states. Members pay the lowest co-pays and coinsurance when they use in-network providers, but PPOs offer some coverage for out-of-network care. PPOs generally don’t ask participants to choose a primary care physician, nor do they require a referral to see a specialist. Many also have a larger network than other types of health plans, making them a flexible option. However, PPO premiums tend to be higher than HMOs.
Private Fee-For-Service Plans (PFFP)
Private Fee-For-Service, or PFFS, plans offer participants flexible health care options. Some PFFS plans use a network of providers, and costs are lower when using in-network care. However, PFFS enrollees can receive care from any provider that agrees to the terms of payment set forth in the plan. In the case of an emergency, enrollees can receive care from any provider or hospital, regardless of whether they’ve agreed to the terms of the plan. The risk is that a provider won’t agree to the terms, so participants should ask if they’re covered prior to seeking treatment. There’s no requirement to select a primary care physician under a PFFS plan, and participants don’t need a referral to see a specialist.
Special Needs Plans (SNP)
Special Needs Plans, or SNPs, are designed to offer coverage to specific populations, such as those with a particular type of chronic illness or financial situation. Some examples include people in nursing homes or those with dementia or cancer. The coverage includes care services that best meet the needs of the plan participants. In addition to the tailored benefits, SNPs are required to offer prescription drug coverage and the same basic coverage as Original Medicare. SNPs aren’t available to everyone who is eligible for Medicare. People enrolling in these plans must have the condition or be in the situation that the SNP is designed for.
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 Connecticut, prescription drug coverage, known as Medicare Part D, is included in most Medicare Advantage plans. Some plans may charge extra for this coverage. People who have a HMO or PPO plan can't also enroll in a stand-alone Medicare Prescription Drug Plan or Medicare Part D. Those that do are automatically removed from Medicare Advantage and re-enrolled in the Original Medicare program. For this reason, it's important that these seniors choose an HMO or PPO plan that includes prescription drug coverage. Some PFFS plans don't include prescription drug coverage, but participants in these plans can join a separate prescription drug plan.
Medicare Advantage offers seniors an invaluable resource for assisting with their health care costs. However, it can be difficult to understand the coverage, choose the right plan and get enrolled. There are different elements to the Medicare Advantage program and a wide variety of plans, so seniors may be confused about how to find the best plan that meets their budget and needs. Below are a range of state and local resources that can help seniors in Connecticut understand and make the most of Medicare Advantage.
Connecticut’s Program for Health Insurance Assistance, Outreach, Information and Referral, Counseling, Eligibility Screening (CHOICES) has a range of services available to assist seniors with Medicare programs including Medicare Advantage. Certified counselors can provide information and objective advice to help individuals understand their health insurance options and make informed decisions. The program also includes eligibility screening and can assist individuals with applications for a range of federal and state benefit programs. CHOICES conducts presentations throughout the state, including at local senior and health fairs. The service is available to people aged 60 and over, and all people eligible for Medicare, including those with disabilities.
To speak to someone about the program or arrange counselling, contact the CHOICES office at 800-994-9422. More information about the program can also be found on the CHOICES website.
The Office of the Healthcare Advocate (OHA) assists Connecticut residents with their health care coverage. The service can provide explanations about benefits, coverage and programs, and offers assessments of the plans offered in Connecticut, including those in the Medicare Advantage program. Seniors who contact the OHA can also receive help with enrollment, understanding their rights and responsibilities and the internal and external appeals process. The OHA acts as an advocate for people who have complaints about their health care coverage and conducts outreach activities including presentations to community groups. The services of this independent agency are confidential and free for residents of Connecticut.
Seniors can contact the OHA at 866-466-4446 and speak to a counselor who can provide information immediately. Complaints and requests for information about participant rights and options can be submitted online through the OHA complaint form.
The Center for Medicare Advocacy is a nonprofit, nonpartisan law organization. Its mission is to improve access to quality health care and comprehensive Medicare coverage for older people and those with disabilities. The organization’s primary services are education, advocacy and legal assistance, and the Center represents people in appeals and pursues coverage for individuals. Information available on the website includes a Connecticut Consumer’s Guide to Medicare and the Center collects stories about Connecticut residents’ Medicare experiences to help them advocate for improved access. The Connecticut Medicare Maximization Project is aimed specifically at appealing denials for care to residents with dual eligibility.
Senior Medicare Patrol (SMP) offers one-on-one counseling to people enrolled in Medicare. This assistance is intended to help beneficiaries understand billing and other paperwork and read their Medicare summary notices. Counselors can also review cases and help beneficiaries report fraud if circumstances are suspicious. SMP has an education arm that delivers presentations and distributes educational materials at community events about types of Medicare fraud and how seniors can protect themselves.
Most Area Agencies on Aging have SMP volunteers available to speak with seniors. The SMP office can be contacted at 800-994-9422 for details on specific offices.
Community Choices, the Regional Aging and Disability Resource Center, has a system of information and access designed to support older adults and people with disabilities. The assistance provided covers a wide range of topics that may concern seniors, including options counselling and benefits screening. On the topic of health care, Community Choices provides information on Medicare, including Medicare Advantage, and other health insurance options. It also helps seniors communicate their needs, and assists people in navigating the system of local, state and federal programs. Assistance applying for programs can also be arranged. Community Choices can connect seniors with additional resources to assist them with Medicare and health care advocacy, including legal services.
Community Choices partners with local Agencies on Aging. Older adults can call 800-994-9422 to access their area's AAA.
The Agency on Aging of South Central Connecticut (AOASSC) has a range of services that assist seniors in the area. This includes assistance with Medicare, Medicare Advantage and other programs and benefits. There is an information library that includes information about Medicare, supplement rates, savings programs and other details seniors may need. The agency also has counselors available to help seniors apply for assistance. Trained Benefits QuickLINK volunteers offer advice on Medicare premiums and programs that can provide financial assistance to older adults.
Seniors can contact AOASSC at 203-785-8533 or via the agency website's online contact form, or visit the office located in North Haven.