Medicare Advantage is privately offered health insurance, also known as Medicare Part C. It is an all-in-one alternative option to the federal Medicare Parts A and B, or Original Medicare, program. Unlike Original Medicare, where all participants receive the same coverage, Medicare Advantage plans have different levels of coverage and cost. All Medicare Advantage plans have to provide the same level of coverage as Original Medicare, but many have additional benefits for members, such as hearing, dental and prescription drug coverage. The out-of-pocket costs for Medicare Advantage participants also tend to be lower than the Original Medicare costs. The downside is that Medicare Advantage plans tend to limit the options participants have when choosing their health care providers.
The popularity of Medicare Advantage varies widely between states. The rate of Medicare Advantage participants across the 50 states ranges from 1% of total Medicare recipients in Alaska to 47% in Hawaii. The rate in Illinois is 27%, which is lower than nearby Wisconsin and Minnesota, which have rates of 46% and 48% respectively. However, the popularity in many other Midwestern states is lower. In neighboring Iowa, the rate is 24%, and in Nebraska, which has the lowest rate in the Midwest, only 19% of Medicare beneficiaries have signed up for Medicare Advantage.
Seniors can choose from many plans through Medicare Advantage, all with their own advantages and disadvantages. However, all plans come in different types, and plans of the same types share certain features. The plans available in Illinois include HMO, PPO, PFFS and SNP plans. Many of these plans also include prescription drug coverage. In this guide, seniors can find explanations of the different types of plans available. It also covers prescription drug coverage options for Medicare Advantage enrollees in Illinois and when seniors can enroll in the program. Seniors looking for help choosing a Medicare Advantage plan that caters to their health and financial requirements can also find a range of state and local assistance options.
There is a wide range of plans available to enrollees of Medicare Advantage. In Illinois, the four types of plans available are 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, are plans centered around a network of doctors and other health care providers. Plan participants must use providers in the plan’s networks in order to have their care covered. Receiving care from out-of-network providers may mean that members have to pay for the full cost of care. Members of HMOs also need a referral to see a specialist and generally need to nominate a primary care physician. Despite the restrictions, HMO plans remain appealing as the premiums tend to be lower than other Medicare Advantage plans.
Preferred Provider Organizations (PPOs)
Preferred Provider Organizations, or PPOs, also use provider networks made up of a group of doctors, facilities, pharmacists and others who participate in the network. There are two versions of PPO plans. The first is a Local PPO, which has a network centered around a particular locality, such as a state or county. The second is a Regional PPO, which may have a network that covers multiple states. PPO premiums tend to be higher than HMOs; however, participants have more health care choices as the networks tend to be larger. Participants also have some coverage when they receive out-of-network care, although co-pays and other costs are lower when using in-network providers. PPO members can usually see a specialist without a referral and don’t need a primary care physician.
Private Fee-For-Service (PFFS)
Private Fee-For-Service, or PFFS, plans offer flexible coverage to Medicare Advantage members. Some plans do use a network of providers that have lower costs for members, but enrollees can receive care from any health care professional that agrees to the plan’s payment terms. As there’s a possibility that the provider won’t agree to payment terms, so it’s important that participants confirm they’re covered before receiving treatment. If a participant requires emergency treatment, they can go to any hospital or health care provider without needing the provider to agree to the terms. PFFS participants don’t need a primary care physician and can see a specialist without a referral.
Special Needs Plans (SNPs)
Special Needs Plans, or SNPs, are designed to meet the needs of specific populations and are only available to Medicare recipients who are members of that population. Most commonly, the plans are tailored for people with particular types of disability or chronic illness, such as dementia or cancer. SNPs can also cater to people in a particular financial or living situation, such as seniors living in nursing homes. SNPs must include prescription drug coverage and provide the same coverage as Original Medicare. In addition, SNPs have additional benefits that provide support and services often required by people with the condition or in the situation focused on by the plan.
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.
Many seniors look for plans that have coverage for prescription drugs. Medicare Advantage plans can include Medicare Prescription Drug Coverage, also known as Medicare Part D. HMO and PPO plans often include this coverage, but there may be an additional charge. People on these plans cannot purchase stand-alone Part D coverage; if they do, they’re removed from their Medicare Advantage plan and returned to Original Medicare. Prescription drug coverage is less common on PFFS plans and people on these plans can purchase stand-alone drug coverage.
Although Medicare is an invaluable resource for many seniors, its vast array of plans and options can be confusing for people new to the program. Each plan has different coverage, costs and elements, so it can be difficult to identify the right plan for an individual’s needs. There is a range of government and other sources at the state and local level that can help seniors navigate the system and find the best coverage. Below are some resources that can help Illinois seniors.
The Senior Health Insurance Program (SHIP) is a free counseling service for Medicare beneficiaries and their caregivers. It hosts a range of Medicare education and application information on its website and seniors can also watch Medicare webinars. The Good Start Medicare page details the steps seniors should take as they approach their 65th birthday to ensure they can make an informed decision about their health insurance. SHIP counselors are located throughout the state to provide advice on the best plan for an individual’s needs, how to apply for Medicare and information about Medicare fraud and abuse.
Seniors can ring SHIP on 1-800-252-8966 to get information about Medicare and other health insurance options. Staff can also direct callers to their nearest SHIP office to arrange a meeting with a trained SHIP counselor. Contact details for local sites can also be found on their website.Visit Website
Senior HelpLine provides free information to seniors aged 60 and older and their caregivers throughout Illinois. The service connects seniors to local services and provides information about a range of topics, such as Medicare Advantage. Professional staff can also evaluate individual caller’s needs and answer questions that can help seniors clarify their options. Staff members have a thorough knowledge of the programs and services available to older adults in the state, including local resources. The service operates Monday through Friday from 8.30 a.m. to 5.00 p.m.
Northwestern Illinois Area Agency on Aging (NIAAA) has an Information and Assistance service that provides free information to older adults and their caregivers. Individual consultations can provide seniors with advice about Medicare and Medicaid programs and eligibility. Staff also help seniors apply for benefits. The service is available over the phone, in NIAAA offices or in the home, if required. There are offices in each county of the northwestern region of Illinois, so seniors can easily connect with local resources.
AgeOptions is the Area Agency on Aging in suburban Cook County. It has trained professionals available to help older adults make informed choices and is a central point of contact for people looking for information about Medicare and other programs. Staff can also help seniors access benefits and other senior services. AgeOptions has a number of advocacy and education programs, including Advisory and Make Medicare Work, which work to educate the professionals who work with older adults and the wider community about Medicare, Medicaid and senior options. AgeOptions can also help seniors with questions about Medicare fraud and abuse.
The Central Illinois Agency on Aging (CIAOA) is an independent nonprofit organization serving people in the central Illinois region. Its mission to empower older adults to control their own lives is furthered by the Information and Assistance program. The service provides information about benefits and services available in the area and connects seniors to community resources that meet their needs. CIAOA also conducts education programs about Medicare fraud and helps seniors with Medicare Part D. The staff are specialists, certified by the Alliance of Information & Referral Systems, and are available Monday through Friday, 8.30 a.m. to 5.00 p.m.
Heartland Human Services provides a range of programs to improve the health and wellness of people in Effingham and Clay Counties. An Information and Assistance program is one of the services available to help seniors. The main focus of the program is directing clients to relevant services. Specialists also offer assistance filling out applications for different benefit programs, including Medicare Advantage, and with legal aid. This is a free service.
Seniors can speak to specialists or make an appointment by calling (217) 347-7179 ext. 1038.