Seniors who are eligible for Medicare in Massachusetts have the option to choose a Medicare Advantage plan as an alternative to Original Medicare. Unlike Original Medicare, which offers the same coverage to every beneficiary, Medicare Advantage plans offer a choice of plans with varying benefits and costs. Medicare Advantage, also known as Medicare Part C, is also provided by private insurance carriers, instead of the federal government. Part C plans also often include benefits not paid for by Original Medicare, such as vision, dental and prescription drug coverage.
Medicare Advantage is a popular choice for seniors across the United States. According to the Kaiser Family Foundation, roughly 39% of Medicare-eligible seniors choose to participate in some type of Part C plan. Rates of participation vary significantly by state, however. In Minnesota and Florida, for example, 48% of beneficiaries choose to join a Medicare Advantage plan, which is the highest state participation rate in the country. At the other end of the spectrum, only 1% of seniors in Alaska opt into a Medicare Advantage plan. Massachusetts falls closer to the low end of participation. Just 24% of seniors in the state have enrolled in a Part C plan to receive their Medicare benefits, which puts Massachusetts 35th in the nation overall for Medicare Advantage participation.
Massachusetts seniors can enroll in Medicare Advantage through one of four basic plan types: HMO, PPO, PFFS or SNP. Each form has its advantages and drawbacks, and it’s important to diligently research each option to determine which one offers the ideal coverage and cost. In this guide, we go over the main types of Medicare Advantage available in Massachusetts and explain how prescription drug coverage and enrollment work in the Bay State. We also provide state and local resources that can help Massachusetts seniors get the most from their Medicare Advantage coverage.
Health Maintenance Organizations (HMOs)
HMOs provide coverage for medical services like any other insurance plan, but the services are mostly delivered by one large organization. Doctors, nurses and other health providers are generally employees of the HMO, and members must seek care from the organization’s provider network. Beneficiaries typically need clearance from their network primary care physician before seeking specialist services, but monthly premiums tend to be lower with HMOs than other plan types.
Preferred Provider Options (PPOs)
In many ways, PPO plans operate much like HMOs, but there tends to be more flexibility in how benefits are delivered. Members of PPO plans usually pay a little more for monthly premiums than HMO plan members, but beneficiaries can often choose from a larger pool of care providers. Unlike with an HMO, PPO providers are not employees of the insurer, but they are grouped into a plan network of independent providers who contract with the PPO to provide care to plan members. PPO members can usually seek care outside of the network, although the plan may pay the provider less for the service.
Private Fee-for-Service (PFFS)
PFFS plans operate much like fully private insurance policies. Members are free to seek out medical care anywhere they wish, and providers may or may not accept the PFFS plan for payment. Providers that do not accept the insurance company’s terms may bill the plan member at private-pay rates. PFFS plans are very flexible in how services are delivered, but they tend to charge high monthly premiums.
Special Needs Plans (SNPs)
SNPs are designed to focus on member benefits for specific health issues, often by reducing coverage in other areas or by charging high monthly premiums. SNPs are often preferred by beneficiaries with diabetes, physical disabilities and other chronic health conditions, since an SNP designed to meet their needs can often be the most efficient way to pay for dialysis, physical therapy or the other specific services a chronic condition requires. Though the monthly cost of an SNP is generally above average for a Part C plan, needs-specific care can be available at significant cost savings for beneficiaries who qualify for this type of coverage. Seniors who have been diagnosed with renal failure are an exception to the general SNP eligibility rule, as this condition is covered directly by Original Medicare benefits.
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 drugs are paid for through Part D plans, which are optional for seniors who qualify for Original Medicare. Medicare Advantage plans often have a Part D component as part of their unified plan coverage, though seniors are still free to purchase a separate prescription drug plan if they wish.
Part C providers in Massachusetts offered 22 prescription drug plans in 2018, and nearly 1 million state residents participate in at least one of them. Premiums for Part D coverage in Massachusetts average $47.25 a month, which is nearly $5 less than the national average. At least four plans offer premiums of less than $25 per month, and eight plans offer $0 deductibles.
Prescription drug plans offered through Medicare Advantage plans in Massachusetts are allowed to charge a range of monthly premiums, though there is a cap on how much may be charged. Providers are also not permitted to discriminate against beneficiaries with preexisting conditions, or to charge more for high-risk participants.
Medicare and Medicare Advantage are invaluable resources for seniors. Plan details and rules for participating in Medicare programs can get confusing, however, and many seniors need help navigating the complex rules governing their coverage and the enrollment process. Below we have listed some of the state and local resources Massachusetts seniors can use to get help with understanding and managing their Medicare Advantage benefits.
SHINE is a nonprofit organization with more than 600 volunteers throughout Massachusetts who are trained to assist seniors who qualify for Medicare and Medicare Advantage coverage. Certified SHINE counselors provide free, unbiased advice and referrals for senior residents of the state who need help signing up for or managing their Medicare benefits. Education and community support are also available for caregivers, family members and other loved ones of seniors enrolled in Medicare.
Seniors who need assistance can call SHINE at 1-800-243-4636 to talk with a certified counselor. Volunteers live and work in every community in the state. Inquiries may be submitted online via the SHINE website’s contact form. Send mail to the address listed in the contact section of the program’s website.
Seniors aged 55 and over who live in and around the city of Boston can receive help with managing their Medicare benefits from Age Strong, a program of the city government. Age Strong counselors and case workers are trained to educate seniors about various free and low-cost services they may be eligible for. The program offers referrals and direct assistance with discount and free prescription drug programs, and case workers can help eligible seniors sign up. Age Strong counselors are also able to help seniors find and apply for other, non-Medicare or Medicare Advantage programs.
Adults who live in the 25 cities and towns of the MetroWest area can get help from the MetroWest Meds Program in finding and applying for pharmaceutical company assistance programs. The MetroWest Meds program can also assist seniors with applications for MassHealth and various Medicare-related programs for people with limited incomes. Eligible seniors must meet program admission standards for income, assets and medical needs, as well as permanently reside in one of the Kennedy CHC’s service areas, which are listed on the program’s website.
Contact the program office by calling 508-270-5781. Walk-in applications are accepted at program offices, though mail is received at the Edward M Kennedy Community Health Center in Framingham.
The city of Mansfield’s Council on Aging (COA) offers outreach services to help local seniors understand and manage their Medicare and Medicare Advantage benefits. Mansfield seniors aged 60 and over, who have a diagnosed disability of any kind, can apply to the council for help signing up for patient assistance programs, finding benefits they may not know they are eligible for and obtaining financial assistance with Part D premiums and co-payments.
Call the COA application line at 508-261-7368 to schedule an appointment with a case worker. Applications and other correspondence may be mailed to: Mansfield Council on Aging – Town Hall
255 Hope Street, P.O. Box 232, Mansfield, MA 02048
Greater Lynn Senior Services (GLSS) helps seniors aged 60 and over in the Lynn area, plus areas around Essex County, find free and discounted prescription drug programs. Eligible seniors must meet income and asset limits, generally capped at 200% of the federal benefits rate. Program coordinators can also help seniors find and apply for privately offered drug supplement programs, Extra Help federal aid for Part D benefits and several other aid programs relevant to residents of the GLSS service area.
Seniors who reside in Essex or Middlesex counties may be eligible for assistance with their Medicare and Medicare Advantage programs through the Disability Resource Center (DRC) in Salem. The mission of the center is to inform local seniors, as well as younger adults with any kind of disability, about how Medicare benefits work together, and available extra assistance that they may be eligible for. Program caseworkers are able to offer unbiased advice, educational materials about each program the center works with and direct assistance filling out the necessary application forms.