Medicare Advantage, or Medicare Part C as it’s sometimes known, is an alternative option to Original Medicare Parts A and B. Instead of getting coverage through the government, Medicare Advantage users purchase plans from private insurance providers, similar to standard insurance. Medicare Advantage plans must offer, at minimum, the same coverage as Medicare Parts A and B, but can include additional options, creating a flexible way for seniors to get the insurance benefits they need. Medicare Advantage can vary greatly in benefits from one plan and insurer to the next. In addition, Medicare Advantage plans can offer prescription drug coverage, which is not an option under Original Medicare.
The usage of Medicare Advantage plans differs widely from state to state. Nationally, around 39% of seniors choose a Medicare Advantage plan instead of Original Medicare, according to the Kaiser Family Foundation. Kentucky’s penetration rate falls slightly below this level at 37%. Kentucky seniors also fall short of the usage rates achieved in some neighboring states; Ohio and Tennessee, for example, have average rates of 42%. However, Kentucky does outperform several of its neighbors, with West Virginia at 33%, Indiana at 35%, Illinois at 27% and Virginia at just 24%.
For Kentucky seniors looking for coverage under Medicare Part C, there are many options to consider. Medicare Advantage plans are sold through a number of providers and are available in a few different forms, including PPOs, SNPs, PFFSs and HMOs. This guide offers an introduction to Medicare Advantage plans in Kentucky, the different plan types available, the options for prescription drug coverage and the rules for enrolling in a plan. Also available is information on several state and local agencies that can help Kentucky residents make empowered Medicare decisions.
Unlike Original Medicare, which is the same for all users, Medicare Advantage plans can differ greatly. In Kentucky, seniors have access to four plan categories: Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-For-Service (PFFS) and Special Needs Plans (SNPs). Each of these plan types has pros and cons, so seniors are encouraged to do their research and speak with a trusted health care resource before choosing a Medicare Advantage plan.
Health Maintenance Organizations (HMO)
HMOs are a popular choice for Medicare Advantage plans. Under a health maintenance organization, plan members must choose doctors and facilities within the plan’s network. Coverage for in-network services is generally quite comprehensive, but little to no coverage is usually available for out-of-network services. In addition to network requirements for reimbursement, a primary care doctor is required to provide a referral to a specialist for coverage of specialist visits. HMO plans tend to be among the most affordable options in exchange for these kinds of restrictions on care. HMOs can provide prescription drug coverage but aren’t required to do so.
Private Fee-For-Service Plans (PFFS)
As the name implies, PFFS plans use a fee-based model in which different kinds of appointments, procedures and treatments are covered on a fee schedule. Each plan has set limits on spending that apply to varying categories of care, and coverage limits are capped at these amounts. However, PFFS plans don’t use the network model in the same way as other alternatives, providing seniors with flexibility when choosing doctors and treatment facilities. Most places that accept Medicare also accept PFFS plans, but not all, so plan members should verify coverage before scheduling any sort of appointment. PFFS plans can be more affordable than other kinds of plans. Some PFFS plans may provide prescription drug coverage, but there’s no plan-specific requirement.
Preferred Provider Organizations (PPO)
PPO plans are very popular options for Medicare Advantage, offering excellent coverage with increased flexibility. PPOs use a network model similar to an HMO, but there’s usually some level of coverage when using out-of-network providers and facilities, saving plan members money. There’s also no requirement for referrals for specialist care. PPOs are generally more expensive than alternative plan types, but for some seniors, the benefits outweigh the costs. This kind of plan can provide coverage for prescription drugs, but it’s not a requirement.
Special Needs Plans (SNP)
SNPs are specialized plans available for those who have specific qualifying disabilities or chronic conditions. Unlike most other kinds of Medicare Advantage plan that offers broad coverage for a wide array of health care needs, SNP plans focus on these designated diseases and conditions in order to provide the best care possible under unique circumstances. SNPs aren’t available to general Medicare users but instead are limited only to those who are eligible. Unlike all other forms of Medicare Advantage plans, SNPs must include coverage for prescription drugs.
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 many seniors in Kentucky, prescription drug coverage is a priority when searching for a Medicare plan option. Many Medicare users have at least some prescription drug requirements, making coverage a good way to lower the costs of care. For people who require this level of coverage, choosing a Medicare Advantage plan with prescription coverage is key. Medicare Part C cannot be combined with a traditional Medicare Part D policy; enrolling in Part D triggers an automatic disenrollment from Medicare Advantage plans. Many Medicare Advantage plans include prescription drug coverage in regular premiums, but others may require an additional monthly cost. Those who already have drug coverage through an employer or union may not be good candidates for Medicare Advantage.
Medicare Advantage plans come in many shapes and sizes, varying by provider, coverage and plan type. As such, it’s not uncommon for seniors to look for assistance in making the right selection for their unique health care needs. These state and local resources can help seniors make the best possible choice when selecting a Medicare plan.
The Kentucky State Health Insurance Assistance Program is a state-sponsored insurance resource for seniors seeking help with choosing and enrolling in a Medicare plan. Assistance includes comprehensive education in plan options and opportunities, such as confidential and unbiased one-on-one phone and in-person counseling, presentations to community groups and the distribution of educational materials regarding Medicare. SHIP also works closely with the Department for Public Health Kentucky Prescription Assistance Program to help seniors maintain access to affordable prescription drugs. All seniors in Kentucky, as well as their family members and caregivers, can use the free resources available through SHIP.
Seniors can access SHIP at 877-293-7447, the state-wide hotline number, or 502-564-6930.
The Department for Aging and Independent Living is a state-offered resource that provides programs and services for aging adults in Kentucky. With a full range of comprehensive care, DAIL focuses on Medicare resources, assisted living, caregiver support, participant-directed services and supported living programs. Seniors, caregivers and family members are welcome to contact DAIL at any time to ask questions, including about Medicare resources in Kentucky. DAIL can also connect seniors with area support services, like local nonprofits and Area Agencies on Aging. Services from DAIL are free to those living in Kentucky.
Kentucky Disability Benefits 101 is a Kentucky-related branch of the World Institute on Disability. While the focus of this organization is on disabled adults, it also provides valuable information about Medicare, including Medicaid interaction for those who are low-income or disabled and require additional benefits. This organization offers comprehensive Medicare information on its website, including how to enroll and the differences between each Medicare Part. The site includes definitions and other information that can help seniors compare plans and understand costs and benefits. Seniors can also learn more about Medicare Savings Programs available in Kentucky. Estimator tools are available to provide a high-level snapshot of potential benefits eligibility. The Kentucky Disability Benefits 101 site is free to use.
The Legal Aid Network of Kentucky is a valuable legal resource for low-income individuals in need of assistance with a wide variety of civil legal issues, including Medicare. The Network’s website provides comprehensive information on Medicare, including eligibility, plans and benefits options. This service offers free access to an attorney for basic questions on civil, noncriminal matters, including Medicare. The Ask a Lawyer feature lets Kentucky residents submit a question to a licensed volunteer attorney for free. Using this feature requires registration, but there’s no fee or subscription required.
The Bluegrass Area Agency on Aging and Independent Living is one of Kentucky’s Area Agencies on Aging, and it covers residents in the Bluegrass region, which includes Anderson, Bourbon, Boyle, Clark, Estill, Fayette, Franklin, Garrard, Harrison, Jessamine, Lincoln, Madison, Mercer, Nicholas, Powell, Scott and Woodford Counties. As a comprehensive resource for aging members of the Bluegrass community, the Bluegrass Area Agency on Aging and Independent Living provides area resources for assisted living and day programs, health and financial benefits, Medicare and Medicaid, and other essential services. Counseling for Medicare services is available for seniors living in the service area. Resources through the Agency are free to those living locally.
The Office for Aging & Disabled Citizens is a government entity operated through the Resilience and Community Services program in Louisville, Kentucky, that advocates for seniors in the metro area. This resource offers assistance to seniors in numerous ways, including connections with nonprofits, Medicare and Medicaid support, disability assistance and access to affordable meals. In addition to providing Medicare support, the Louisville Office for Aging & Disabled Citizens also operates a Medicare Patrol program that ensures seniors aren’t victims of Medicare abuse or fraud. All residents of Louisville are welcome to use the government resources provided through this office.
Seniors can contact the Louisville Office for Aging & Disabled Citizens at 502- 574-4377.