Medicare Advantage, or Medicare Part C as it is sometimes known, is an alternative to Original Medicare that is purchased through private insurance companies, rather than obtained through the government. While these plans must offer, at minimum, the same options available under Original Medicare Parts A and B, they can also offer additional benefits for seniors with varying needs. Medicare Advantage plans can also include prescription drug coverage, which is not a part of Original Medicare.
Medicare Advantage plan usage rates can vary significantly from state to state. Nationally, the Kaiser Family Foundation reports that around 34% of Medicare users choose Medicare Advantage plans. Delaware falls below this mark substantially with just 15% of the state’s residents choosing to use Medicare Advantage over Original Medicare. Delaware’s penetration is higher than that of neighboring state Maryland at 11% and slightly below the 18% usage rate in Washington D.C. New Jersey and Pennsylvania are higher, however, with average rates of 28% and 41%, respectively.
Not all Medicare Advantage plans are equal. In addition to being offered by a wide range of private insurance companies, plans are also available in four distinct plan types, each with its own pros and cons: HMOs, PFFSs, PPOs, and SNPs. This guide offers an overview of the types of Medicare Advantage plans available in Delaware, including resources Delaware seniors can contact when looking for objective information about choosing the right plan.
Seniors in Delaware have several forms of Medicare Advantage plans to consider, each with unique advantages and disadvantages. These plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-For-Service (PFFS) and Special Needs Plans (SNPs). When considering the available plans, seniors should weigh the pros and cons in the context of their own individual health care needs.
Health Maintenance Organizations (HMO)
HMOs are a popular choice for Medicare Advantage members, providing comprehensive care at lower prices. HMOs are predicated on the presence of a network; covered care must be performed by an approved provider, and out-of-network services may not be covered at all. With an HMO, members cannot see specialists without a referral from a primary care provider. HMO plans are usually among the most affordable options on the market. These plans can include coverage for prescription drugs, but that is not a requirement.
Private Fee-For-Service Plans (PFFS)
Private fee-for-service plans utilize a fee schedule in lieu of a traditional network concept, unlike most other forms of insurance plans. This means that reimbursement limits for procedures are predetermined, leaving plan members to pay whatever isn’t covered. The advantage is that these plans can often be used with any provider or facility that accepts Medicare, offering more flexibility. PFFS plans are often more affordable than some of the alternatives. However, members may be required to verify coverage and pricing before procedures, which can be inconvenient. PFFS plans can feature prescription drug coverage, but they are not required to do so.
Preferred Provider Organizations (PPO)
PPOs are among the most common choices for Medicare Advantage plans. While a network is used in a way similar to an HMO, the rules of coverage are less iron-clad; in many cases, out-of-network care is covered to some degree. Further, there is no need to solicit a referral from a primary care physician before scheduling an appointment with a specialist. Although prescription drug coverage is not a requirement for these plans, it may be included in some plans. Most PPOs are more expensive than other types of Medicare Advantage insurance but the increased flexibility can be a large benefit to many seniors.
Special Needs Plans (SNP)
Special needs plans, as the name implies, are specialized plans used to cover care for those with unique disabilities and medical conditions. These plans are less general than other forms of Medicare Advantage plans. Instead, these plans are specially arranged to cover specific conditions in order to maximize available care. Unlike other kinds of plans, SNPs must include prescription drug coverage. Only those with qualifying medical conditions can purchase 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.
Prescription drug coverage will likely be an important part of the process of choosing a Medicare Advantage plan for most seniors. As it is not possible to combine Medicare Part D coverage with Medicare Advantage — enrolling in a Medicare Part D plan can result in automatic disenrollment from a Medicare Part C plan — seniors must choose a plan that meets both their medical and their medication needs. In some cases, coverage is included in the plan premium, but in others, this can be an additional amount every month. Those who already have prescription drug coverage through an employer or union should not choose Medicare Advantage over Original Medicare Parts A and B.
Choosing the right Medicare Advantage plan can be a big endeavor, especially for those who are new to Medicare. For some seniors, Medicare Advantage, in general, won’t be the right choice, so comparing the pros and cons can be very important in making the right decision. These state and local resources in Delaware can help seniors evaluate options and make an educated choice.
The Delaware Medicare Assistance Bureau (DMAB), previously known as ELDERinfo, is the State Health Insurance Program for the state of Delaware. A free resource for all seniors on Medicare, as well as those under 65 who will soon enroll in Medicare, DMAB offers comprehensive insurance counseling to help seniors make the best possible choice. Through this organization, seniors can receive counseling on Original Medicare, Medicare Advantage, Medicare Part D plans, medical assistance programs, long-term care insurance and Medicare billing problems. As a resource of the state, this program can be used as often as necessary, with no limits on access. DMAB also offers extensive written guides on Medicare for seniors to use when starting the selection process. In-person meetings with counselors are also available, as are Welcome to Medicare live information sessions at locations around the state.
Seniors can contact the Delaware Medicare Assistance Bureau at 1-800-336-9500 or 1-302-674-7364 to schedule a counseling session.
The Delaware Division of Services for Aging and Adults with Physical Disabilities is a state agency put in place to support the needs of seniors and those with disabilities, with integrity, dignity and respect. As an advocacy organization, seniors can access a wide range of information related to aging and available state resources, including Medicare and Medicaid. Seniors with questions about Medicare and other state services that cover medical costs and other aging-related programming can contact the free helpline. This service is available to all aging residents of Delaware, as well as those with physical disabilities.
Seniors can contact the Delaware Division of Services for Aging Adults and Adults with Physical Disabilities by phone at 1-800-223-9074.
Delaware Consumer Assistance Center for Consumer Information & Insurance Oversight is a government agency organized under the Affordable Care Act. This program offers consumer assistance for a wide range of insurance-related resources throughout the state, including private employer-sponsored health insurance, Medicaid, Veteran’s Affairs and Medicare. Seniors and individuals with health insurance questions or concerns can contact the Delaware Consumer Assistance program for access to free and confidential support. This program is open to all residents of Delaware, including seniors seeking help with Medicare resources.
The Delaware Aging and Disability Resource Center (ARDC) is a comprehensive resource for seniors and those with disabilities throughout the state of Delaware. Seniors can contact the ARDC with questions about services in the state of Delaware, including health care resources, as well as general services seniors can use to access financial assistance, meals and more. Comprehensive counseling resources are also available to seniors seeking assistance. The website features a service search feature that pairs seniors with the applicable available opportunities throughout the state. The ARDC serves seniors throughout the state of Delaware.
The Delaware Senior Medicare Patrol Program is a resource that helps seniors determine the validity of information included in Medicare summaries and supports educated decision-making in choosing or switching Medicare plans. This department serves as a way for seniors to stay informed and to report any potential fraud or abuse within the Medicare system. Seniors can also review plan data, ask questions and learn more about the features included in their chosen plans. This service is available to anyone using Medicare in the state of Delaware.
The Delaware Senior Resource Network is a collection of senior resources available throughout the state to help seniors connect with the right support systems to meet their needs. This network partners with organizations that offer money management, end of life planning, health care planning, home health care and legal assistance, providing seniors with a wealth of trusted resources. Meetings take place four times a month. Seniors throughout Delaware can take advantage of the connections available through the Delaware Senior Resource Network
Seniors can call the Delaware Senior Resource Network at 1-302-442-4069.