Medicare benefits start once an individual reaches age 65. By default, seniors are enrolled in Original Medicare, which provides hospital coverage (Part A) and medical coverage (Part B). Medicare Advantage, also called Medicare Part C, is an alternative to Original Medicare. In addition to including health care services covered by Part A and Part B, Medicare Advantage plans may feature additional benefits, such as hearing, dental, vision and prescription drug coverage.
Medicare Advantage plans have grown in popularity over the past decade. In 2009, approximately 23% of seniors had Medicare Advantage plans, instead of Original Medicare. By 2020, that number grew to 39% of seniors. In Indiana, about 35% of seniors are enrolled in Medicare Advantage. Three of Indiana’s neighboring states have higher percentages of seniors with Medicare Advantage, including Michigan (45%), Ohio (42%) and Kentucky (37%). In Illinois, which borders Indiana from the west, 27% of seniors are enrolled in Medicare Advantage.
Hoosier seniors have several types of Medicare Advantage plans to choose from, including HMO, PPO, SNP, PFFS and MSA plans, each of which offers unique benefits and drawbacks. In this guide, we cover the five main types of Medicare Advantage plans and what events make an individual eligible for enrollment. We also feature several state and local resources for seniors who want to speak with experienced Medicare Advantage advisers.
There are several different types of Medicare Advantage plans for Indiana seniors to choose from, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Special Needs Plans (SNPs), Private Fee-for-Service plans (PFFSs) and Medical Savings Account plans (MSAs). Generally speaking, members with Medicare Advantage plans pay the premium for Medicare Part B, and in some cases, there is an additional monthly premium for the plan itself.
Health Maintenance Organizations (HMO)
HMO plans generally provide health care coverage from doctors, specialists and hospitals that are within the plan’s network, except in the event of an emergency or if urgent care is needed when the member is traveling. Compared to other Medicare Advantage plans, HMOs typically have modest premiums, but members are more limited in their care options. Except in special circumstances, seniors who receive medical care from a health care provider that’s not in their plan’s network may be responsible for the entire cost of care. In most cases, members have to choose a primary care doctor, and referrals are required to see a specialist. Most HMO plans include prescription drug coverage.
Preferred Provider Organizations (PPO)
Like HMOs, PPO plans have in-network doctors, specialists and hospitals. These plans typically have lower premiums because members agree to use a network of health care providers to get the most affordable co-pays. While a member’s PPO plan typically covers out-of-network providers, the member pays a significantly higher co-pay for services. In addition to the plan’s monthly premium, members pay standard co-pays for medical services and hospital stays, along with a percentage of the cost for some services. Members don’t have to choose a primary care doctor, and in most cases, referrals aren’t necessary to see a specialist. Most PPO plans include prescription drug coverage.
Special Needs Plans (SNP)
An SNP is a Medicare Advantage coordinated care plan that provides targeted care and limits enrollment to special needs individuals. A special needs individual may be one who is dually eligible for Medicare and Medicaid, who resides in a nursing home or who has a condition, such as diabetes or chronic heart failure. Members are typically required to visit health care providers within their plan’s network, except for emergency and urgent care or if they have end-stage renal disease and need out-of-area dialysis. In most cases, members have to choose a primary doctor, and referrals are required to see specialists. All SNPs have prescription drug coverage. Seniors may join an SNP at any time.
Private Fee-for-Service (PFFS)
Medicare PFFS plans differ from other Medicare Advantage plans because the plan, not Medicare, determines how much it pays doctors, specialists and hospitals for covered services. Some PFFS plans have networks of health care providers that have agreed to always treat plan members. Members may also choose Medicare-approved out-of-network providers who accept the plan’s terms, but they typically pay higher co-pays. Some PFFS plans have prescription drug coverage, but if a member’s plan doesn’t have this coverage, they may join Medicare Part D. Members don’t need to choose a primary care doctor, and they don’t need a referral to see a specialist.
Medical Savings Account (MSA)
Consumer-directed MSA plans combine high-deductible Medicare Advantage plans with a medical savings account that is used to pay for medical expenses. The Medicare Advantage plan only covers health care costs after the member reaches a high yearly deductible. The MSA plan deposits funds into a special savings account that can be used toward services until the deductible is met. MSA plans cover all the Medicare services that Original Medicare covers, and some plans have additional benefits, such as dental, vision and long-term care. They don’t have prescription drug coverage, but members can add Medicare Part D coverage for an additional monthly premium. Members can choose their health care services and providers.
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.
Medicare prescription drug coverage, which is provided by Medicare Part D, is an optional benefit that is available to everyone who qualifies for Original Medicare. To avoid paying a late enrollment penalty, seniors who want prescription drug coverage should opt for a Medicare Advantage plan with this coverage, called an MA-PD plan when they’re first eligible. In Indiana, Part D coverage can be added to certain types of Medicare Advantage plans, including PFFS and MSA plans. Seniors who add Part D to their MSA or PFFS plan generally pay two separate premiums, including one for their Medicare Advantage plan and one for prescription drug coverage. If seniors with an MA-D plan enroll in Medicare Part D, their plan will disenroll them, and they’ll go back to Original Medicare.
Indiana’s Senior Health Insurance Program provides free, unbiased health insurance information for those who qualify for Medicare. It is staffed with a team of volunteer counselors who have completed an intensive training course and are certified by the Indiana Department of Insurance. SHIP isn’t affiliated with any insurance companies or agencies, and it doesn’t sell insurance plans. Some services that it provides include help with understanding Medicare and organizing records, information on how to file Medicare claims and appeal Medicare decisions and an overview of a Medicare beneficiary’s rights. Its counselors also assist clients in evaluating the various Medicare Advantage plans available to them and provide referrals to appropriate agencies that address other needs. To be eligible for assistance from SHIP, seniors must qualify for Medicare coverage. SHIP also offers educational materials and brochures and provides speakers to make presentations for groups, clubs and senior centers.
To locate their nearest SHIP office, seniors should call 1-800-457-8283 or text 1-855-463-5292.
MHS Indiana is the state’s managed care entity that provides access to health insurance for at-risk populations, including low-income residents and seniors. It is a subsidiary of Centene Corporation, a multinational health care enterprise that offers government-sponsored health insurance and specialty services. Through MHS, seniors can enroll in Allwell, the state’s Medicare Advantage plan, as well as Medicare’s Extra Help program, which covers prescription drug costs for low-income seniors. MHS also connects Hoosiers with experienced case managers who can help them evaluate their needs and choose the best health care plan, as well as member service representatives who can help them understand their coverage or file a claim. Program eligibility is based on an individual’s age, and in some cases, special health needs. MHS also has a 24-hour nurse line that seniors can call to receive medical advice.
The AdvoConnection Directory provides a comprehensive list of private independent health advocates throughout Indiana. This free directory features nonmedical advocates and navigators who are members of the Alliance of Professional Health Advocates and have experience in helping clients work with medical providers and health insurance companies. Some services that advocates may provide include accompanying clients to medical appointments, helping them learn more about their medical condition, teaching pain management techniques and reviewing their prescriptions and over-the-counter medications to ensure that there are no conflicts. Advocates may also provide assistance with selecting a Medicare Advantage plan, filing a claim, disputing denials and finding legal assistance after a medical error. This directory is available to anyone, regardless of age, income or health status. TheAdvoConnection Directory also provides a variety of informational resources on topics, such as long-term care, preparing for hospital stays and reporting medical events.
To find an advocate, seniors can visit the AdvoConnection website, enter their zip code and select the services they’re looking for from the menu. Once the search results are provided, seniors can select the service provider that meets their needs and contact them directly.
LifeTime, which is located in Dillsboro, Indiana, provides a variety of services and supports for seniors residing in Dearborn, Jefferson, Ohio, Ripley and Switzerland Counties. It has a team of Family Support Options Counselors that provide free, objective advice to help seniors evaluate their needs and budget to find a suitable Medicare Advantage plan. To be eligible for services through LifeTime, seniors must be at least 60 years old and reside in the agency’s service area. Along with Medicare counseling, LifeTime provides transportation services, meal delivery, advocacy and community care counseling, as well as information and assistance. It provides referral services to connect seniors with other relevant community resources. The office also features an on-site resource library with books, videos and pamphlets on topics, such as family caregiving, as well as a computer with Internet access that is available to use during the library’s hours of operation.
CICOA Aging & In-Home Solutions is located in Indianapolis and serves seniors living in Boone, Hamilton, Hancock, Johnson, Marion, Morgan and Shelby Counties. This nonprofit organization has an Aging and Disability Resource Center that provides one-on-one counseling for seniors regarding available health care benefits and long-term services. The agency makes this service available for free to everyone, regardless of their income or financial assets. In addition to providing information about Medicare Advantage plans, the agency promotes seniors’ independence and wellness through several options programs, including home accessibility modifications, transportation and senior meals and nutrition services, as well as care management and care coordination services. It also provides presentations and display materials for community events.
Seniors can contact CICOA’s Indianapolis office by calling 1-317-254-5465 or 1-800-489-9550 on weekdays from 8:00 a.m. to 5:00 p.m. Seniors can also call the Morgan County office at 1-317-803-6061. To speak to someone about options counseling, seniors should call the agency’s Aging and Disability Resource Center at 1-317-803-6131 or 1-800-432-2422.
The St. Joseph Health System, which is based out of the northern region of Indiana, provides health insurance services to Michiana seniors. It features resource centers in Mishawaka, Plymouth and South Bend, each staffed with licensed health insurance agents who provide information on Medicare and prescription drug plans. All services are offered free of cost or obligation, and they are available to all Michiana residents regardless of age or income. Along with providing information on Medicare Advantage plans, it educates clients about vision, dental, cancer and critical illness insurance to help them reduce out-of-pocket medical expenses. No application or appointment fees are charged. It also hosts free events throughout the year where licensed health insurance agents answer visitors’ questions about Medicare and other types of health insurance.