Medicare Advantage is a type of health insurance that includes all the same benefits as Original Medicare. Administered through private insurance companies and regulated by federal and state governments, MA plan costs and coverage varies, and costs are subject to change on an annual basis. Unlike Original Medicare, Medicare Advantage, also called Medicare Part C, may include supplemental benefits, such as prescription drug benefits, dental and vision care and preventative health services.
Florida ranks high when it comes to Medicare Advantage enrollment. According to a report from the Kaiser Family Foundation, in 2020 43% of eligible Florida residents were enrolled in a Medicare Advantage plan, which is 9% higher than the nationwide MA enrollment rate. Within Florida, enrollment is 48% in Volusia County and 67% in Miami-Dade County. By comparison, just 19% of eligible seniors have MA in Okaloosa County, and enrollment sits at 11% in Monroe County.
Seniors who want to purchase a Medicare Advantage in Florida have a variety of options. HMO, PPO, and PFFS plans are all available, as are SNPs for those who meet specific, government-regulated criteria. This guide covers the four Medical Advantage plan options in Florida and enrollment criteria, as well as prescription drug coverage for Medicare Advantage members. We’ve also compiled a list of agencies that can help seniors choose the right Medicare Advantage plan for their needs.
Four basic types of Medicare Advantage plans are available in Florida, including Health Maintenance Organization (HMO) plans, Preferred Provider Organization (PPO) plans and Private Fee-for-Service (PFFS) plans. There is also a restricted-enrollment Special Needs Plan (SNP) for Florida residents who meet specific eligibility criteria.
Health Maintenance Organizations (HMO)
Health Maintenance Organizations provide health insurance that includes coverage for services rendered through in-network doctors and medical professionals. HMO Medicare Advantage plans tend to be priced lower than other types of MA plans. To control costs, HMOs usually restrict access to specialists by requiring members to get a referral from their primary physician. HMO members aren’t prevented from seeking out-of-network care; however, HMOs generally only cover in-network services. Some HMOs in Florida now offer Medicare Advantage and Prescription Drug Plans, known as MA-PDs. These plans combine Medicare Part A, Part B and Part D to provide members with prescription drug benefits that are comparable to the benefits offered through a stand-alone Part D plan.
Private Fee-For-Service (PFFS)
Private Fee-For-Service or PFFS plans are flexible private insurance plans that give members the option to see any doctor, hospital or provider, whether or not the provider is within the PFFS plan network. In-network co-pays are lower than co-pays for out-of-network services, and PFFS premiums are usually much higher than other types of Medicare Advantage plans. PFFS plan members do not need to designate a primary care physician, and members can self-refer to a specialist.
Preferred Provider Organizations (PPO)
As with PFFS and HMO plans, Preferred Provider Organizations, or PPO Medicare Advantage plan members need to see an in-network provider 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.
Special Needs Plans (SNP)
Special Needs Plans, or SNPs, are HMO plans that are only available to those who qualify for Medicare and Medicaid, commonly called dual-eligible. SNPs are also open to enrolment for those who are institutionalized in a care facility and/or have specific chronic disabilities or diseases. SNPs are designed to improve service delivery and reduce costs while covering additional services to meet the unique needs of medically-fragile members. By law, all 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.
In Florida, prescription drug coverage is included in all Medicare Advantage Prescription Drug plans, known as MA-PD plans. By law, Medicare Advantage Special Needs plans also need to include Part D Medicare prescription medication coverage.
With close to 500 unique Medicare Advantage plans available in Florida, finding the right one can be challenging for seniors and their loved ones. Plan availability is different in each county, and costs and coverage can vary. To help make the selection process easier, we’ve compiled a list of statewide and local resources that assist seniors with Medicare Advantage selection and management.
Florida’s Serving Health Insurance Needs of Elders (SHINE) program is a free Medicare counseling service administered through the Florida Department of Elder Affairs and delivered through local Area Agencies on Aging. A network of SHINE volunteers provide free, unbiased information about area Medicare Advantage plans, pricing and coverage options through one-on-one counseling appointments and workshops. Seniors who have questions about Medicare or need help choosing the best Medicare Advantage plans for their particular needs can book an appointment with a SHINE counselor.
Seniors can connect with their local SHINE provider by calling the Florida Department of Elder Affairs at 1-800-963-5337.
Florida’s Department of Elder Affairs helps protect seniors against Medicare Advantage fraud, misuse and over-billing through the Senior Medicare Patrol program. Administered in conjunction with the SHINE program, the FL-SMP is available to seniors who have questions or concerns about their MA plan. SMP workers will assess every report made, and issues that need to be escalated are referred to the appropriate local, state or federal authorities. SMP volunteers also deliver free workshops on Medicare fraud prevention at senior centers throughout the state.
Seniors, family members and caregivers can contact the FL-SMP through the Florida Department of Elder Affairs by calling 1-800-963-5337. FL-SMP services are also available through local Area Agencies on Aging, also known as Aging and Disability Resource Centers (ADRCs).Visit Website
Florida seniors aged 60 and older can schedule a free telephone consultation with an approved attorney or paralegal through the statewide Senior Legal Helpline. Geared towards low-income seniors, this service can help seniors navigate legal issues related to Medicare Advantage coverage, as well as other civil matters. If Senior Legal Helpline callers require legal services beyond the free telephone consultation, they will be given the help they need to find a free or low-cost legal provider in their community.
Seniors can call the Senior Legal Helpline toll-free at 1-888-895-7873.
The Medicare Savings Program is a state-sponsored subsidy program for low-income seniors who have difficulties covering the cost of Medicare. MSP consists of four separate programs that help seniors pay for their Medicare premiums, coinsurance, co-payments and deductibles. Eligibility is based on income, resources and medical expenses.
The Senior Connection Center is the Aging and Disability Resource Center for Hardee, Hillsborough, Highlands, Manatee and Polk counties. Seniors, adults with disabilities and caregivers can access free and low-cost services, such as evidence-based health and wellness workshops and fall prevention classes. The center also hosts the local SHINE program to help seniors learn about the various Medicare options, including which Medicare Advantage plans are offered in the area. SHINE volunteers can also assist with Medicare billing issues and advise seniors about financial aid programs to reduce out-of-pocket Medicare costs.
To learn more about services at the Senior Connection Center, seniors can call 1-800-963-5337.
Seniors First is a nonprofit organization that provides community-based services to seniors aged 60 and older throughout Orange County. Services are designed to help seniors remain in their own homes as long as possible, in order to delay or prevent institutionalization. Low-income seniors with Medicare Advantage may qualify for case management, personal care and homemaker services. The organization also operates a medical equipment bank for seniors and disabled adults living in Osceola, Seminole and Orange counties.
For more information about Seniors First programs and services, seniors can call 1-407-292-0177 in Orlando or 1-863-534-5320 in Bartow.
The Sunshine Center of St. Petersburg is a city-owned multi-service center that offers a variety of services for seniors aged 55 and older. The center is focused on health and wellness programming, advocacy and educational opportunities. Seniors can access free information on local social service agencies and resources, such as senior nutrition programs, barrier-free transportation and financial aid. The center also offers unbiased Medicare counseling, including assistance with local Medicare Advantage plans.