Medicare Advantage plans, sometimes called Medicare Part C, are an alternative to Original Medicare. Unlike the federal government’s Original Medicare, applicants get their Medicare Advantage plans from private companies approved by the federal government to offer Medicare coverage. Medicare Advantage plans must cover everything in Medicare Part A (hospital insurance) and Part B (medical insurance), but plans can also include other services, such as dental, vision and prescription drugs. Because the provider decides how much you pay for covered services, costs vary.
According to the Kaiser Family Foundation, the majority of the 64 million people nationwide on Medicare were covered by traditional Medicare in 2019. However, 34% of Medicare beneficiaries were enrolled in a Medicare Advantage plan. The popularity of Medicare Advantage varies significantly from state to state, with enrollment as low as 1% in Alaska and as high as 44% in Hawaii. Louisiana has an enrollment rate of 36%, which places it slightly above the nationwide average, along with 21 other states, including neighboring Texas, which also has a 36% enrollment rate.
Louisiana seniors interested in enrolling in Medicare Advantage have numerous plans and insurance providers to choose from, including Health Maintenance Organizations, Preferred Provider Organizations, Private-Fee-for-Service Plans, Special Needs Plans and Medical Savings Account plans. This guide provides details on the five types of plans available, enrollment and eligibility requirements and prescription drug coverage. For Louisiana enrollees who need additional assistance determining which Medicare Advantage plan is right for them, this guide also provides state and local resources that offer further information about health care coverage through the Medicare program.
There are several types of Medicare Advantage plans for seniors to explore. In Louisiana, the types of plans available may differ by parish. Options may include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service Plans (PFFS), Special Needs Plans (SNP) and Medical Savings Accounts (MSA).
Health Maintenance Organizations (HMO)
Health Maintenance Organizations, or HMOs, tend to have lower premiums than other Medicare Advantage plans, but health care options are more limited. Typically, participants must choose a primary care provider within the plan’s network for partial coverage of their cost of care, and they need a referral from their primary doctor before seeing a specialist. Barring a point-of-service option, participants who obtain services from nonnetwork providers may have to pay the entire cost for nonemergency care themselves. Prescription drugs are usually covered in HMO plans, but it’s not required, and members aren’t allowed to sign up for separate prescription drug coverage under Medicare Part D if a drug plan isn’t included.
Preferred Provider Organizations (PPO)
Preferred Provider Organizations, or PPOs, usually have higher premiums, but they offer more flexibility. Participants aren’t required to choose a primary care provider, but providers must be within the plan’s network for the best coverage rates. While a PPO covers part of the cost for a nonnetwork provider, members pay the lowest co-pay and coinsurance rates by staying within the network. Plan members typically don’t need a referral to see a specialist, but seeing a network specialist costs less. Like HMOs, PPOs usually cover prescription drugs, but it’s not required, and participants can’t sign up for Medicare Part D if prescriptions aren’t included.
Private Fee-for-Service Plans (PFFS)
Private Fee-for-Service Plans, or PFFS, may or may not include a network. Plan members with a network can see any network provider who agrees to always treat plan members or see a nonnetwork provider who accepts the plan at a higher cost. PFFS plans without a network allow members to see any Medicare-approved health care provider or hospital that agrees to treat plan members and accepts the plan’s payment terms. PFFS plans may cover prescription drugs, but if they don’t, participants can sign up for a Medicare prescription drug plan.
Special Needs Plans (SNP)
Special Needs Plans, or SNPs, tailor benefits, provider choices, and drug plans to meet the unique member needs and aren’t available to all Medicare participants. Membership is limited to people with certain types of disabilities, diseases or chronic illnesses and, sometimes, living in a specific location. For example, Humana offers an SNP specifically for Medicare participants with chronic cardiovascular disorders, congestive heart failure and diabetes mellitus living in Louisiana’s Orleans or Jefferson Parish. Members usually must choose a primary care provider within the plan’s network of providers, or the plan may require a care coordinator to help members with their health care. Members typically need a referral before seeing a specialist. Unlike all other Medicare Advantage plans, SNPs must provide prescription drug coverage.
Medical Savings Accounts (MSA)
Medical Savings Accounts, or MSAs, are similar to Health Savings Account plans found outside of Medicare. MSAs combine a high-deductible plan with a special savings account. A member’s plan only begins covering their health care costs once they meet their high yearly deductible, which varies by plan. At the same time, the plan deposits money into the member’s savings account, and the member can use it to pay for health care services before they meet their deductible. These plans allow members to choose their own health care providers but don’t include prescription drug coverage, so members must sign up for Medicare Part D.
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.
Not every Medicare Advantage plan in Louisiana includes prescription drug coverage, but those that do are sometimes called MA-PDs. In most cases, HMOs and PPOs cover prescription drugs and may require a separate monthly premium. If the plan doesn’t include drug coverage, participants can’t join a prescription drug plan through Medicare Part D or they lose their Medicare Advantage plan. Prescription drugs also may be covered in PFFS plans, but under these plans, participants can sign up for Medicare Part D when the plan doesn’t offer drug coverage. All SNPs are required by law to provide prescription drug coverage.
Medicare is a valuable program that provides health insurance coverage to seniors, yet many people don’t understand how the program works and how it can help them. Complex applications and enrollment processes also hinder participation. Some seniors become overwhelmed with all the Medicare choices and need help navigating the various benefits, coverages, premiums, co-payments, coinsurances, deductibles and other program elements. To help counter this confusion, many resources provide personalized Medicare counseling, and they’re usually free to qualifying applicants. Listed below are some state and local resources in Louisiana that guide seniors through the Medicare system and help them make the most of their coverage.
Available through the Louisiana Department of Insurance, the Senior Health Insurance Information Program provides counseling services to Medicare beneficiaries throughout Louisiana from offices located all around the state. Trained counselors offer unbiased, one-on-one guidance over the phone or face-to-face for seniors and disabled persons with proof of state residency who have Medicare or will soon enroll in Medicare. SHIIP counselors help beneficiaries better understand Medicare coverage options and benefits to protect them from paying too much for medical care and prescription drugs. Medicare counseling is completely free and confidential. SHIIP counselors can also explain private insurance options to beneficiaries who find that Medicare doesn’t cover all their costs, but no one will ever try to sell anything to program participants.
The Governor’s Office of Elderly Affairs serves as the focal point for Louisiana’s seniors as the State Agency on Aging and the administrator of the Older Americans Act program services. GOEA administers a broad range of statewide programs and services through its network of agencies, including 64 parish Councils on Aging and 36 Area Agencies on Aging. Agency services are intended to assist persons aged 60 and older at offices located in various parishes throughout the state, with an emphasis on low-income individuals. These offices assist seniors with a wide range of aging issues free of charge. Services include Medicare counseling to answer questions about Medicare coverage, simplify the eligibility process and assist with Medicare Part D selection.
To assist older adults and disabled individuals within the state of Louisiana, the GOEA has expanded the state’s Aging and Disability Resource Centers and SenioRX Programs to assist with the unmet needs of underserved community members. ADRC offices are located throughout the state, and each office serves multiple parishes or regions. Services are free of charge to anyone, regardless of age, ability or income. For Medicare-eligible seniors, ADRC provides annual Medicare checkups to ensure they’re getting all the benefits they desire. Benefits counselors are also available to assist with applications and offer free counseling for seniors and preretirees with questions about Medicare, Medicare Advantage, Medicare Supplement Insurance, Prescription Drug Plans and Medicaid.
The New Orleans Council on Aging administers the Aging and Disability Resource Center for the parishes of Orleans, Plaquemines and St. Bernard. The ADRC is a collaborative effort of the Administration for Community Living and the Centers for Medicare & Medicaid Services and offers counseling on Medicare and Medicaid enrollment. This is a free service that provides answers and guidance to seniors and adults with disabilities, including Medicare counseling, assistance with Part D selection, and advice about the Prescription Assistance Program available for anyone needing help paying for their medications and Medicare beneficiaries in the Part D coverage gap known as the donut hole.
For seniors living in the parishes of Bienville, Bossier, Caddo, Claiborne, DeSoto, Red River, Natchitoches, Sabine and Webster, the Caddo Council on Aging offers information and counseling on Medicare and long-term care options from its Shreveport office. Seniors age 60 or older or disabled adults age 21 or over can talk with trained counselors, free of charge, who help them navigate complex insurance programs and answer questions on Medicare coverages, benefits and so on. Counselors can also assist with filling out Medicare Part D applications and finding the best plan each year, and they help low-income individuals complete applications for discounted medicines from drug companies.
The Jefferson Council on Aging, located in Metairie, operates an Aging & Disability Resource Center for seniors and adults with disabilities who reside in Jefferson, St. Charles, St. James and St. John the Baptist Parishes. Trained counselors provide unbiased one-on-one health insurance counseling, including information on Medicare, Medicaid and other insurance issues. Medicare counseling includes assisting beneficiaries with issues concerning eligibility, enrollment, claims, appeals, fraud, prescription drug coverage, financial assistance for medicines due to a coverage gap or donut hole and other program elements. This ADRC also provides options and solutions regarding health care and disability coverage, resource referrals and advocacy.
For more information about the ADRC services available at Jefferson Council on Aging, call 504-207-4690. Those living out of the area may call toll-free at 1-800-635-1437.