Medicare Advantage plans, also commonly known as Medicare Part C, are available to Original Medicare beneficiaries as an alternative to Part A and B coverage. In contrast to the federal government-run Original Medicare program that provides identical coverage to all enrollees, Medicare Advantage plans are offered by Medicare-approved private insurers and the costs and coverage levels can vary. Many Medicare Advantage plans also include extra benefits unavailable through Medicare Parts A and B, such as routine vision, dental and hearing care and prescription drug coverage.
According to the Kaiser Family Foundation, 34% of Medicare beneficiaries nationwide have chosen to enroll in Medicare Advantage plans. The popularity of these plans differs from state to state. At 33%, enrollment in Maine is just one point below the national average. However, it’s much higher than in neighboring New Hampshire and Massachusetts, where the enrollment rates are 17% and 22%, respectively. Medicare Advantage enrollment drops to 11% in nearby Vermont but increases substantially to 37% in Rhode Island and 39% in Connecticut.
Seniors considering enrolling in Medicare Advantage can choose between different types of plans offered by several insurance companies. There are HMO, PPO, PFFS and SNP plans available, as well as MA-PD plans that provide prescription drug coverage. This guide explains the four types of Medicare Advantage plans offered in Maine, the prescription drug coverage options available to plan enrollees and when Medicare beneficiaries can enroll in an Advantage plan. We’ve also included resources for Maine seniors who need help deciding which Medicare Advantage plan is right for their needs.
There are different types of Medicare Advantage plans that beneficiaries can choose from. In Maine, seniors have a choice of four types of plans: Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-For-Service Plans (PFFSs) and Special Needs Plans (SNPs). There are also two subtypes of HMO and PPO plans offered in Maine: Regional plans that are available statewide and local plans that are offered only in specific counties.
Health Maintenance Organizations (HMO)
Health Maintenance Organizations, or HMOs, generally have lower premiums than other types of Medicare Advantage plans, but the care options with HMOs are more restrictive. For services to be covered, HMO plan members must receive care from physicians and other providers within the plan’s defined network. If an out-of-network provider is used, an enrollee may have to pay for the entire cost of care or the services received. Seniors enrolled in HMOs are required to choose a primary care physician, and they typically need a referral from their PCP before being seen by specialists.
Preferred Provider Organizations (PPO)
Preferred Provider Organizations, or PPOs, have a network of providers for enrollees to use, but they are more flexible and typically have higher premiums than HMOs. PPO members pay lower co-pays when using providers on the plan’s preferred list, but they may see physicians and service providers outside the network at a higher cost. Referrals are not usually needed to see specialists.
Private Fee-For-Service Plans (PFFS)
Private Fee-For-Service Plans, or PFFSs, offer enrollees the greatest flexibility in their choice of health care providers and facilities. Enrollees are not restricted to receiving care from a specific network of approved providers and are free to use any provider or facility that accepts the plan’s negotiated terms. Monthly premiums tend to be higher for PFFP plans, and not all providers accept the rates offered by the plan.
Special Needs Plans (SNP)
Special Needs Plans, or SNPs, are only available to specific groups of Maine Medicare beneficiaries. A group may be comprised of individuals who reside in an institutional setting, are dually qualified for Medicare and Medicaid or have a qualifying disability or health condition, such as diabetes or end-stage renal disease (ESRD). SNP plans must provide Part D prescription drug coverage, and the benefits, and the provider network of each plan is typically tailored to the needs of the group it serves. In emergencies, or if out-of-area dialysis is needed for ESRD, members may be covered for services received outside their plan’s network.
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.
Maine seniors who wish to enroll in a Medicare Advantage plan that covers the cost of prescription drugs must choose an MA-PD plan that specifically includes this coverage. Members of Medicare Advantage plans in Maine cannot sign up for separate Part D prescription drug plans without automatically voiding their Medicare Advantage plan coverage. The cost of prescription drug coverage premiums depends on the plan chosen and the insurer. Some Medicare Advantage plans include prescription drug coverage in the standard premium. Other MA-PD plans require that enrollees pay an additional monthly premium for their prescription coverage. The list of covered drugs also varies between plans and insurance companies, so seniors should compare formulas, along with plan benefits and premium costs, to choose a Medicare Advantage plan that meets their medication coverage needs.
Medicare Advantage can be an important resource for Maine seniors, but understanding all the available options and getting enrolled is not always easy. The array of plan types, the various coverage options and the complexities of the enrollment process can make choosing and signing up for the right plan a daunting task. We’ve listed some state and local resources that can help make navigating the process less onerous, so seniors can maximize the benefits they receive from their Medicare Advantage coverage.
The Maine Department of Health and Human Services oversees the state Medicaid program known as MaineCare, which can offer valuable financial assistance for seniors enrolled in Medicare. Eligible seniors may qualify for the state’s Medicare Savings Program (MSP) and receive help paying their Medicare Advantage and prescription drug plan premiums. The program may also cover other out-of-pocket costs, such as coinsurance payments and deductibles. To qualify for the MSP, seniors must meet the program’s income and asset guidelines. Eligibility determinations and enrollment in the MSP are handled by the Maine DHHS Office of Family Independence.
Seniors can learn more about qualifying for the MSP and apply for the program by contacting the OFI Eligibility Office at 1-855-797-4357. Applications are also accepted at OFI district offices throughout the state, and a list of office locations is available on the department’s website.Visit Website
The Senior Medicare Patrol (SMP), is a federally funded, volunteer-based organization whose goal is raising awareness of and reducing Medicare fraud and abuse, as well as billing errors. In Maine, SMP volunteers hold workshops in various locations and offer one-on-one counseling sessions to provide information, answer questions and address concerns that seniors have about health insurance services, including Medicare Advantage, other Medicare programs and MaineCare. Cases of suspected fraud or other criminal activities that are brought to the organization’s attention are referred to an appropriate local, state or federal agency.
To learn more about the assistance available through SMP and how to contact an organization volunteer for help with a concern, seniors can call the Maine Office of Elder Services at 1-800-262-2232. Alternatively, they can contact their local Area Agency on Aging.Visit Website
The State Health Insurance Program (SHIP) offers in-depth, unbiased information about Medicare and other health insurance options to Maine residents. The program provides Medicare-eligible seniors and adults with disabilities with one-on-one counseling at no cost, either by phone or in person. Trained SHIP counselors are available to provide guidance and answer questions about Original Medicare, Medicare Advantage, Part D prescription drug coverage and MaineCare. They can also help seniors with state assistance, such as the Medicare Savings Program, which can help lower prescription drug and out-of-pocket health care costs for eligible individuals.
Seniors can learn more about the SHIP program by calling the Maine Office of Aging and Disability Services toll-free at 1-800-262-2232. To receive assistance through the SHIP program, seniors can contact their local Area Agency on Aging to schedule a counseling session, either over the phone or in-person at the agency’s location.Visit Website
The Maine Health Insurance Consumer Assistance Program (MHICAP) assists seniors and other state residents with a range of health insurance coverage concerns. The program is administered by the nonprofit Maine advocacy organization, Consumers for Affordable Health Care, and is available throughout the state. Services are provided at no charge and include help learning about available coverage options, assistance applying for health insurance and handling coverage and claim denials, among others. Experienced MHICAP counselors can also help seniors apply for assistance through the state Medicaid program, MaineCare, which can reduce or cover their Medicare Advantage and prescription drug costs.
For assistance with Medicare Advantage and other health insurance issues, seniors can call the MHICAP toll-free helpline at 1-800-965-7476. For more information and answers to questions about the program, seniors can contact Consumers for Affordable Health Care’s Augusta office by phone at 1-800-838-0388, or by completing the contact form on the CAHC website.Visit Website
Maine Legal Services for the Elderly is a not-for-profit organization that provides free legal advice to seniors aged 60 and older on a range of issues, including health insurance, public benefit programs, civil and personal legal matters and Medicare programs, such as Medicare Advantage. Seniors can access detailed information about a variety of Medicare topics on the organization’s website, or call the statewide toll-free helpline to receive personalized assistance from a Medicare Rights Advocate. One-on-one help with Medicare concerns is also available at the LSE offices located in Augusta, Bangor, Scarborough, Lewiston and Presque Isle.
For information or advice about Medicare issues, seniors can call the LSE helpline at 1-800-750-5353 and ask to speak with a Medicare Rights Advocate. Seniors can also search for the LSE location serving their county on the agency’s website, and contact the office directly for assistance.Visit Website
The five Aging & Disability Resource Centers (ADRCs) located throughout Maine connect seniors and those with disabilities to a wide range of resources, programs and services, including help understanding the different Medicare coverage choices and enrollment options. Each center can put seniors in touch with experienced Medicare consultants who can provide information about the various types of Medicare Advantage plans and their prescription drug coverage options. These trained professionals can also offer guidance to help seniors define their coverage needs and select a plan that works best for their unique situation. Assistance with completing applications is also available. These services are provided free of charge.
Maine’s Aging and Disability Resource Centers are operated by the five Area Agencies on Aging that serve specific regions of the state. Seniors can view the state map showing the service areas for each center, and find the contact details for the ADRC serving their area on the Government of Maine website.Visit Website