Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare Parts A and B. Instead of using government-provided plans, Medicare Advantage users purchase plans from third-party private insurance companies. This provides a significant variety of plan options from which to choose, as all Medicare Advantage plans do not offer the same benefits. With varying tiers, companies and costs, all plans are different with varying coverage opportunities. Medicare Advantage plans can also include prescription drug coverage, which is not an option with Original Medicare.
The rate of use for Medicare Advantage plans differs from state to state. On a national level, around 34% of Medicare users choose Medicare Advantage, according to the Kaiser Family Foundation. Georgia’s enrollment is around the national average with 36% engagement. This is similar to neighboring states, such as Alabama and Tennessee, but lower than Florida, which has one of the highest rates of use at 40%. Georgia engagement rates are far higher than South Carolina, the state’s neighbor to the north; only 27% of South Carolinians choose Medicare Advantage.
For Georgia seniors seeking care under Medicare Part C, there are many options to choose from. Residents can pick between a number of providers, as well as varying plan types, such as PPOs, SNPs, PFFSs and HMOs. This guide provides an overview of Medicare Advantage in Georgia, including the different types of plans, prescription drug coverage and enrollment rules. We’ve also included resources for Georgia seniors who may need help choosing the right Medicare Advantage plan for their needs and budget.
All Medicare Advantage plans are not made equal. In Georgia, seniors can choose from plans that fall into a few different categories, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-For-Service (PFFS) and Special Needs Plans (SNPs). There is no one best choice; what works for one senior may not be right for another. Seniors are encouraged to do their due diligence and speak with trusted health care resources before making a decision.
Health Maintenance Organizations
HMOs are insurance plans in which members must choose in-network primary care providers and hospitals to have their medical expenses covered. If care is received out-of-network, it is likely that no part of the costs of services will be covered. Unlike other plans where users can choose to seek specialist care when required, HMOs usually require referrals from primary care physicians prior to making an appointment with a specialist. Premiums for HMOs can be lower than other plans, but the limitations on use can offset potential savings. HMOs can provide prescription drug coverage, but they are not required to do so.
Preferred Provider Organizations
PPOs offer more flexibility than HMO plans in exchange for higher plan costs. While members can only receive full coverage for services by an in-network provider, some portion of out-of-network care is usually covered. However, coverage in these circumstances is far more limited, so members are encouraged to stay in-network to save money. PPO members can also see specialists without a referral from a primary care provider. Some PPO plans also offer prescription drug coverage, but it is not required.
Private Fee-For-Service Plans
PFFS plans prespecify the extent to which particular doctors, specialists and services will be covered. Using this fee model, plans payout to the stated limits and no further. Unlike PPO and HMO plans that are bound by networks, some PFFS plans apply to all providers or services approved for Medicare, regardless of any kind of network. There is no need to choose a primary care doctor or get specialist referrals with a PFFS plan. Not all PFFS options include prescription drug coverage, but some plans may. Plans can be less expensive than alternatives, but members are advised to contact every hospital or doctor to determine coverage eligibility prior to scheduling an appointment or a treatment procedure.
Special Needs Plans
SNPs are intended to provide access to care for specific populations of people, rather than the general public. This usually includes those with disabilities or who have specific types of chronic illnesses. These plans provide coordinated care to best serve unique medical needs, creating a connection between insurance providers and medical providers. Unlike other plans, SNPs are required to provide prescription drug coverage. Not all Medicare candidates can choose SNP plans; these plans are generally only available to those to whom specific covered situations apply. Plans are catered to these covered conditions, so users should choose carefully to maximize care options.
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.
For Georgia Medicare members, prescription drug coverage can be included in plans of all types, but it is not required to be a part of HMO, PPO or PFFS plans. SNPs are required to offer prescription drug coverage. In Georgia, anyone who wants prescription drug coverage must choose a plan that includes this; there is no way to combine Medicare Advantage plans with traditional Medicare Part D. Those with prescription drug coverage through an employer or union should not move forward with Medicare Part C plans. Enrolling in a Medicare Part D plan results in automatic disenrollment from a Medicare Advantage plan, defaulting back to Original Medicare. Some plans include prescription drug coverage with standard premiums, but others may charge an additional amount.
Medicare Advantage can be a great choice for seniors, but it isn’t right for everyone. The process of choosing a plan and enrolling can be overwhelming for those new to Part C coverage. With so many different plan types available in Georgia, help can be essential to finding the right fit. These are some of the state and local resources in Georgia that can assist seniors in navigating the Medicare selection process.
GeorgiaCares is a partnership between the Georgia Department of Human Services (DHS) and the Division of Aging Services (DAS) that provides free access to unbiased Medicare assistance. As the State Health Insurance Assistance Program, all seniors eligible for Medicare can use this resource to find the right Medicare enrollment option, as well as those seeking other forms of insurance support. The program is not associated with any insurance companies or providers, guaranteeing objective information on available insurance options. Counseling is available free of charge and can assist with understanding plan descriptions, explanations of benefits and the enrollment process. GeorgiaCares can also connect Medicare beneficiaries with financial assistance programs for those unable to afford premiums or out-of-pocket costs.
To get started with GeorgiaCares, seniors can call 1-866-552-4464 and choose option four on the menu. Contact is also possible through the Department of Aging Services or area Agencies on Aging.Visit Website
The Georgia Division of Aging Services is a subdivision of the Department of Human Services that advocates for the rights of seniors across the state of Georgia. As a comprehensive resource for seniors, this agency offers various forms of information and support to empower and protect the aging population. In addition to offering information on widespread community resources, the Division of Aging Services can also connect seniors with their local Agency on Aging location. Agencies on Aging can be excellent resources for seniors in need of support, offering information on medical insurance, such as Medicare, connecting seniors with financial assistance and providing assistance with costs of services, such as long-term care. Many Agencies on Aging can also provide confidential and unbiased counseling services to help seniors make educated decisions about health and welfare. All seniors and their caretakers in the state of Georgia can seek assistance from the Division of Aging Services.
The Georgia Department of Community Health is one of Georgia’s four health agencies committed to fostering healthy and empowered communities throughout the state. While the primary focus is Medicaid and PeachCare, Georgia’s subsidized insurance plan for children, Medicare information is available as well, including state-level updates on enrollment and how Medicare works with other health services throughout the state. Interested seniors can contact the Department of Community Health to learn more about how Medicare can support health care needs in the state of Georgia. This agency can also help support those seniors who qualify for both Medicare and Medicaid simultaneously and need help balancing benefits. All citizens of Georgia are welcome to seek assistance from the Georgia Department of Community Health.
The Georgia Department of Community Health can be contacted by phone at 1-404-656-4507 or through the contact forms on their website.
Georgians for a Healthy Future is a consumer-focused health care advocacy group serving communities across the state of Georgia. The organization is dedicated to ensuring all Georgia residents have access to comprehensive health insurance, regardless of their chosen course of coverage. Georgians for a Healthy Future advocates for health care reform and is active in public policy changes. Seniors who need assistance with health insurance requirements can reach out to learn more about doctors, coverage options, tax implications and more. Anyone in Georgia seeking information about health insurance or who wants to get involved in health care advocacy is welcome to contact Georgians for a Healthy Future.
Empowerline is an Atlanta-based advocacy group that supports the needs of seniors and those with disabilities in the greater metro area. The organization covers many different topics for seniors, including comprehensive health care plan information. Free certified counselors are available around the clock to answer questions, provide information and help seniors and persons with disabilities make educated choices. This includes information about different Medicare plans, including Part C options, to ensure seniors understand their options and are able to find an affordable plan that meets their individual health needs. Empowerline also offers occasional in-person seminars on a variety of topics, including health insurance.
Senior Citizens Inc is a registered nonprofit agency that offers a variety of services encompassing physical, mental and emotional health support for seniors. This includes counseling services for Medicare participants. A representative with GeorgiaCares works directly with the organization to provide unbiased evaluation assistance. This service is available on Wednesdays from 1:00 p.m. to 5:00 p.m. In addition to Medicare counseling services, the agency can also provide numerous other services to seniors, including meal delivery, companionship through a companionship program, learning center access throughout the state and resources for in-home care. The organization serves four metro areas in Georgia: Chatham, Bryan, Effingham, and Liberty.
Senior Citizens Inc is available by phone locally at 1-912-236-0363 or toll-free at 1-866-579-2116.