Page Reviewed / Updated - May 25, 2020
Medicare Advantage is an alternative to Original Medicare Parts A and B that is available to seniors in Iowa and elsewhere around the country. Sometimes referred to as Medicare Part C, Medicare Advantage is purchased through private insurance companies rather than provided through the government. These plans can vary greatly in price and coverage options and provide seniors with increased flexibility. Some also offer prescription drug coverage, which is not an option under Original Medicare.
Medicare Advantage use varies from one state to the next. According to the Kaiser Family Foundation, around 34% of Medicare users choose Medicare Advantage on a national level. Iowa's Medicare Advantage average is below this, with just 21% of Medicare users choosing a Part C plan. This is on par with Illinois, but far lower than Minnesota and Wisconsin, which utilize Medicare Advantage at rates of 43% and 41%, respectively. Use is higher than some neighbors to the west, however; South Dakota has an enrollment rate of 19%, while only 16% of Nebraska residents choose Medicare Advantage.
Seniors in Iowa who opt for Medicare Advantage over Original Medicare have many kinds of plans to choose from. Plans are available from various insurance providers and in four main types: HMOs, PFFSs, PPOs and SNPs. This guide serves as a source of information for seniors considering their Medicare Advantage options. In addition, it includes Iowa-specific resources that seniors can use to aid in making decisions about plans and plan types.
Medicare Advantage plans are available in a few different forms in Iowa, each with its own pros and cons. These plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-For-Service (PFFS) and Special Needs Plans (SNPs). Seniors choosing between plan types need to consider their unique health care needs when selecting a Medicare Part C plan.
Health Maintenance Organizations (HMO)
Health Maintenance Organizations, better known as HMOs, are a form of insurance plan in which care services are concentrated within a network. In-network care is generally covered, but a procedure provided by an out-of-network doctor or hospital may not be covered at all. In addition to the limitations of working within a network, plan members must also receive a referral from their primary care provider to see a specialist. However, HMO plans tend to be more affordable than other insurance types. Prescription drug coverage may be included, but isn't required in HMO plans.
Private Fee-For-Service Plans (PFFSP)
Private Fee-For-Service Plans operate on a fee-based model rather than a standard network model. Reimbursements are based on the payment amounts stated in each plan rather than agreements with in-network providers and facilities. Flexibility is the main benefit of PFFS plans; as there is no conventional network, plans can be used at any provider that accepts Medicare, including specialists when needed. However, this usually requires verifying in advance whether providers and facilities accept the plan. In exchange, these plans tend to be more affordable than some of the alternatives. PFFS plans may include prescription drug coverage, but they are not required to do so.
Preferred Provider Organizations (PPO)
Preferred Provider Organizations, or PPOs, are among the most common plan options due to the elevated level of flexibility and reimbursement opportunities. While PPOs utilize a network model similar to HMOs, there is usually some level of services covered out of network. In addition, there is no need for a referral to see a specialist. PPOs are more expensive than most other plan types, but the benefits can be worth the extra cost. Some PPO plans offer prescription drug coverage, but this isn't required.
Special Needs Plans (SNP)
As the name implies, Special Needs Plans are designed to support those with unique medical needs, such as specific disabilities or chronic illnesses. To ensure enrollees' care needs are met with all necessary services, these plans are tailored to these qualifying medical conditions. SNPs are required to offer prescription drug coverage. Despite the advantages of SNPs, these plans aren't available to everyone; interested seniors must have a qualified medical condition to purchase a 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.
Prescription drug coverage can be very important for those who rely on Medicare health insurance. Not all Medicare Advantage plans cover prescription drugs, so seniors who need this coverage must choose a plan that includes this benefit. Doing so is especially important because enrolling in a Part D plan will result in automatic termination of a senior's Medicare Advantage coverage and reenrollment in Original Medicare. Those who have drug coverage through a union or employer should not choose Medicare Advantage. Additionally, some plans have prescription coverage included in standard premiums, others require an additional monthly payment.
The Medicare enrollment process can be overwhelming, and seniors may not always know how to choose the right plan for their needs. These statewide and local resources can help Iowa seniors compare Medicare Advantage plans to make an informed decision about which one best suits their health care needs.
Senior Health Insurance Information Program (SHIIP) - Senior Medicare Patrol (SMP) is Iowa's state-run State Health Insurance Program, offering dedicated information to seniors seeking assistance about Medicare and other health insurance topics. One major facet of what SHIIP-SMP offers is counseling for seniors considering their Medicare options. This program allows seniors to ask questions, receive information and compare Medicare Advantage and Original Medicare plans with the help of a highly trained and unbiased professional health care counselor. The website also contains valuable information seniors can use when making Medicare decisions, including Medicare misconceptions and testimonials about how the SHIIP-SMP program has helped others. In-person Welcome to Medicare seminars are also hosted periodically throughout the state. All seniors using Medicare and those soon to turn 65 who want information about their Medicare options can take advantage of the services SHIIP-SMP has to offer.
Seniors can contact the SHIIP-SMP program at 800-351-4664 to ask questions or schedule a counseling session.
The Iowa Department on Aging is the branch of the state government that supports the needs of all aging Iowa residents. Here, seniors can find information, services and events that pertain to aging resources throughout the state. This includes Medicare support and assistance seniors can use to make educated decisions. The Department of Aging also sponsors LifeLong Links, a program that connects seniors with resources in their local area, including the five Area Agencies on Aging operating throughout the state. These organizations provide access to local resources as well as state-level programs and services.
Seniors can contact the Iowa Department on Aging toll-free at 800-532-3213 or locally at 515-725-3333.
Aging Resources of Central Iowa is a senior-specific agency serving Boone, Dallas, Jasper, Madison, Marion, Polk, Story and Warren counties. Seniors living in the region can access a wealth of free resources through this organization, including an Information and Assistance hotline. Highly trained benefits experts are available Monday through Friday from 8:00 a.m. to 4:30 p.m via the hotline to answer questions about Medicare, as well as other health and aging-related services available in Central Iowa. All seniors and their families or caregivers living within the agency's service area have free access to the services provided by Aging Resources of Central Iowa.
Seniors can contact Aging Resources of Central Iowa at 515-255-1310 or 800-747-5352. The Information and Assistance hotline can be reached by calling 515-255-1310 or via email at [email protected].
Milestones is an Area Agency on Aging located in Eastern Iowa that serves seniors in Appanoose, Clinton, Davis, Des Moines, Henry, Jefferson, Keokuk, Lee, Louisa, Lucas, Mahaska, Monroe, Muscatine, Scott, Van Buren, Wapello and Wayne counties. Through Milestones, seniors have access to a wealth of resources related to health care and more. This includes access to comprehensive information about Medicare plans and policies, both via phone counseling and in-person appointments at the Davenport and Ottumwa offices. Free and confidential, this support service allows seniors to receive answers to their Medicare questions, compare plans and make educated decisions. Seniors in Eastern Iowa have full access to all Milestones programming. Seniors living outside of the local area can access select assistance opportunities.
Milestones can be reached by calling 855-410-6222 or 319-752-5433 for the Burlington office, 563-324-9085 for the Davenport office and 641-682-2270 for the Ottumwa office. Emails can be sent through the agency website's contact page.
The Northeast Iowa Area Agency on Aging, or NEI3A, serves Allamakee, Black Hawk, Bremer, Buchanan, Butler, Chickasaw, Clayton, Delaware, Dubuque, Fayette, Grundy, Hardin, Howard, Jackson, Marshall, Poweshiek, Tama and Winneshiek counties. With support for independent seniors, caregivers and persons with disabilities, NEI3A can connect eligible individuals with a wide variety of resources across the region. This includes Medicare counseling for seniors who qualify, offering free, confidential and unbiased information to assist in decision-making. Through this service, seniors can ask questions, clarify plan details and compare Medicare Advantage plans.
Seniors living in one of the counties served can call 800-779-8707 or complete a request for information form on the organization's website.
One of the largest Area Agencies on Aging in the state, Elderbridge serves 29 counties across North Central, Northwest and Central Iowa. This organization is committed to providing trusted information that empowers seniors, with resources that range from health care to fitness. Medicare assistance services through Eldercare are vast, including a Benefits Enrollment Center that allows for easy enrollment in select plans as well as a Medicare Savings Program. The Iowa Senior Medicare Patrol is also a valuable service, ensuring seniors understand their plan options and are aware of signs of Medicare abuse and fraud. In addition, Eldercare offers comprehensive, free Medicare counseling, empowering seniors to make educated decisions with the aid of a confidential counselor. Elderbridge services are available to all seniors within the agency's service area, as well as their caregivers and families.
Seniors can contact Elderbridge at 800-243-0678 or 641-424-0678 for the Mason City office, 515-955-5244 for the Fort Dodge office, 712-792-3512 for the Caroll office or 712-262-1775 for the Spencer office. A contact form is also available on the agency's website.