Medicare Advantage, or Medicare Part C, is a Medicare program that allows seniors to select and enroll in a health insurance plan of their choosing. Medicare Advantage plans are provided through private insurance companies and often include benefits such as vision care, dental care and prescription drug coverage not covered in Original Medicare Parts A and B.
A report compiled by the Kaiser Family Foundation shows that in Maryland, Medicare Advantage enrollments comprised 18% of the state’s total Medicare enrollments in 2019. While a significantly smaller percentage than the national average of 34%, Maryland enrollment is higher than nearby Washington, D.C., and Delaware, but lower than most other East Coast states. With 41% enrollment, Pennsylvania has the highest participation rate in Medicare Advantage in the region.
Because Medicare Advantage plans, while approved by Medicare, are provided by private insurance companies, plans can vary significantly by type, costs such as co-pays and coinsurance, provider networks and included benefits. Maryland seniors eligible for Medicare and interested in Medicare Advantage can choose from four plan types: HMOs, HMO-POS plans, PFFS plans and MSAs. Prescription drug coverage is provided through Medicare Part D, which Maryland seniors can obtain by enrolling in a Medicare Advantage plan that includes prescription drug coverage or by enrolling in a stand-alone Part D plan. In this guide, we provide an overview of these four plan types and the enrollment process and include a list of state and local resources to help seniors further explore their individual plan options.
Maryland’s four Medicare Advantage plan types allow seniors to select a type with the cost and coverage best-suited to their individual needs. Maryland seniors can enroll in one of the following plan types: Health Maintenance Organizations, Health Maintenance Organization plans with a Point of Service option, Paid Fee-for-Service and Medical Savings Accounts.
Health Maintenance Organizations (HMO)
Health Maintenance Organizations, or HMOs, are a type of health insurance plan that works with a specific network of preferred medical providers. These plans are often more affordable than other plan types, but to receive covered services, participants can only see and receive care from the in-network providers. If participants do receive services from an out-of-network provider or facility, they will likely have to pay 100% of the cost. Additionally, participants must usually choose a primary care physician for basic medical needs such as wellness checks and undiagnosed conditions. To see an in-network specialist, participants of HMOs generally must also first request and receive a referral from their PCP.
Health Maintenance Organization Plans-Point of Service (HMO-POS)
HMOs with a point of service option are similar to basic HMO plans in that they have a network of providers participants must use to receive full cover, but the POS option allows participants to visit some out-of-network providers, at a higher cost. HMO-POS plans also require participants to designate a PCP, but don’t usually require referrals to see a specialist. Additionally, some services may require prior authorization from a participant’s PCP. These plans also come with two separate deductibles, one for the HMO in-network care and one for out-of-network POS care.
Paid Fee-For-Service (PFFS)
Paid Fee-For-Service, or PFFS, plans are flexible health insurance plans that decide how much money doctors, medical facilities and other providers receive for the services they provide. Plan participants can visit any provider and receive their health benefits as long as the provider agrees to the plan’s terms. While some PFFS plans may have a list of in-network providers that have agreed to the plan’s terms in advance and through which prices may be lower, participants are still covered for services out-of-network if the provider accepts the plan’s terms. Some plans may include prescription drugs, but if they don’t, participants may elect to enroll in a Medicare Part D prescription drug plan.
Medical Savings Accounts (MSA)
Medical Savings Accounts, or MSAs, are high-deductible plans paired with a savings account designated specifically for health care costs incurred by the plan participant. The plan deposits money from Medicare into the account, and participants may use these funds to pay for health-related expenses. If participants use all of the funds before the next enrollment period, they must pay the Medicare-approved amount out-of-pocket for services until they meet the plan’s deductible. Once participants reach the deductible, the plan covers the remainder of Medicare services they receive for that year. Dental and vision coverage may be available with some plans at an added cost, but participants seeking prescription drug coverage would need to enroll in a stand-alone Medicare Part D 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.
Medicare offers many seniors the option to pay a separate premium to receive prescription drug coverage through a Medicare Part D plan. Some HMO, HMO-POS and PFFS Medicare Advantage plans in Maryland, however, allow seniors to obtain prescription drug coverage directly through their primary health care plan without having to pay a separate premium.
Participants who opt for HMO or HMO-POS plans must select one that includes prescription drug coverage if they would like prescription drug benefits for that year. If their HMO plan doesn’t include prescription drug coverage, they aren’t eligible to enroll in a separate Medicare Part D Plan.
PFFS plans may or may not include prescription drug coverage, but if a participant enrolls in a plan that doesn’t have it, they may still enroll in a stand-alone Medicare Part D plan. MSAs don’t include prescription drug benefits, so MSA participants seeking that type of coverage would also need to enroll in Medicare Part D.
While Medicare Advantage plans can offer seniors more control over their health care, greater coverage and increased flexibility, understanding their plan options and finding the right type of plan for their needs can be a daunting task. To help seniors access resources in their area that provide Medicare-related support and expertise, we’ve included a list of several local and statewide organizations and programs throughout Maryland.
Maryland’s Senior Health Insurance Assistance Program is a statewide network of highly trained volunteers who specialize in helping seniors understand, enroll in and navigate Medicare. Seniors can receive one-on-one counseling in person or over the phone to learn about and discuss topics such as Medicare Advantage plans, long-term care insurance, Medigap policies and prescription drug coverage. Counselors can help seniors compare plans, complete applications, better understand their medical bills and recognize and report abuse or fraud.
One of the Maryland Department of Aging’s primary goals is to help seniors and their loved ones easily access and understand the resources and supports available to them throughout the state. The Department promotes seniors’ health and well-being by financing certain supportive services, coordinating programs and partnering with organizations that provide seniors with Medicare information and assistance. These include SHIP, Area Agencies on Aging, the Senior Medicare Patrol program, financial abuse prevention and the Maryland Access Point program.
To reach the Maryland Department of Aging, seniors can call 410-767-1100 or 800-243-3425 or visit the office at 301 West Preston Street, Suite 1007, Baltimore, Maryland 21201.
Maryland’s Senior Medicare Patrol is a program that connects seniors to volunteers who help them become aware of potential Medicare fraud, spot medical billing errors and report concerns and scams. Seniors can receive confidential, one-on-one counseling either over the phone or at an SMP office, with counseling at-home available for some seniors with mobility issues. SMP volunteers are also available to give educational group presentations.
The Maryland Insurance Administration helps Maryland insurance consumers by providing detailed information on the many types of insurance programs and options throughout the state. Seniors can contact the administration or visit its website to read consumer publications on understanding their health insurance rights and coverage, view a Medicare supplement webinar and file complaints. Information is also available on annuities, dental plans and life insurance.
To contact the Maryland Insurance Administration, seniors can call toll-free at 1-800-492-6116 or visit the office at 200 St. Paul Place, Suite 2700, Baltimore, MD 21202.
Maryland Access Point, or MAP, is a statewide initiative to provide seniors and people with disabilities with access to information, resources and programs regarding long-term care. Spread throughout the state, 20 MAP centers offer Medicare counseling services, legal assistance and one-on-one guidance to help seniors develop a long-term care plan with housing, financial assistance and more. Additionally, The MAP website has an online resources directory seniors can use to find support programs local to their area.
The Anne Arundel County Department Aging and Disabilities offer local seniors a comprehensive list of area resources and programs. Seniors can contact the Department to access services and information on low-cost health care, an aging resource database, adult public guardianship and administrative care coordination. The Department also runs a Legal and Financial Aid program that provides seniors with free assistance with issues regarding Medicare, guardianship, nursing home residence and other health-care-related areas.
Seniors can contact the Anne Arundel County Department Aging and Disabilities office by calling 410-222-4257. They can also visit either of its two locations at 7320 Ritchie Highway, Glen Burnie, MD 21061 and 2666 Riva Road, Annapolis, MD 21401.