Also known as Medicare Part C, Medicare Advantage is privately offered health insurance that’s available as an alternative to Original Medicare Parts A and B. While Original Medicare is a federal program that provides the same coverage to all participants, Medicare Advantage plans have different levels of coverage and costs. At a minimum, all Medicare Advantage plans must offer the same level of coverage as Original Medicare, but many provide additional benefits, such as vision, dental and prescription drug coverage.
In Michigan, 38% of Medicare participants are enrolled in Medicare Advantage. This is slightly higher than the nationwide rate of 34%. The popularity of Medicare Advantage varies widely from state to state, but Michigan’s enrollment rate is on the higher end of the spectrum. Nine states have a higher enrollment rate, including neighboring Wisconsin with a rate of 41% and Hawaii, which has the highest rate of 44%. Many nearby states have a much lower enrollment rate, including Indiana and Illinois, with rates of 29% and 23%, respectively.
There are different types of Medicare Advantage plans available to seniors, with each offering different advantages and drawbacks. In Michigan, there are HMO, PPO, PFFS and SNP Medicare Advantage plans available, and many include prescription drug coverage. This guide will explain the different types of plans, the prescription drug coverage options for Medicare Advantage enrollees in Michigan and when seniors may enroll in a plan. There are also some resources available for seniors who would like more help finding the right Medicare Advantage plan for their financial and health circumstances.
Health Maintenance Organizations (HMOs)
Health Maintenance Organizations, known as HMOs, are an appealing option for seniors as they often have lower premiums than other Medicare Advantage plans. The lower cost does mean there are more limitations on the care available. HMOs have a network of doctors and other health care providers that plan participants must use to have their care costs covered. If seniors receive care from an out-of-network provider, they may have to pay for the full cost. Members of HMOs generally need to select a primary care physician and get referrals to see specialists.
Preferred Provider Organizations (PPOs)
Networks of providers are also used by Preferred Provider Organizations. Also known as PPOs, these organizations have a group of doctors, facilities, pharmacists and others who agree to participate in the network. There are local PPOs with networks covering one or more counties, and regional PPOs with networks that cover one or multiple states. Many PPOs also have larger networks than other types of health plans. PPO premiums tend to be higher than HMOs, however participants get greater flexibility in their care options. Co-pays and coinsurance are lowest when members use in-network providers, but there is some coverage available for out-of-network care. Typically, PPO members don’t need to choose a primary care physician, or obtain a referral to see a specialist.
Private Fee-For-Service (PFFS)
Private Fee-For-Service, or PFFS, plans are among the most flexible health care options available through Medicare Advantage. Some PFFS plans have a network of providers, and offer lower costs for members who use in-network care. However, enrollees can receive care from any health care provider that agrees to the plan’s payment terms. There is the possibility that the provider won’t agree to these terms, so participants should check that they’re covered before receiving treatment. In an emergency, enrollees can receive care from any hospital or health care provider, regardless of whether they agree to the terms. Participants of PFFS plans don’t need to select a primary care physician or get referrals to see specialists.
Special Needs Plans (SNPs)
Special Needs Plans, known as SNPs, offer health care coverage tailored to meet the needs of specific populations. Most commonly, these plans cover particular types of disabilities or chronic illnesses, such as dementia or cancer, or people in a particular financial or living situation, such as those in nursing homes. SNPs must include prescription drug coverage. They must also provide the same basic coverage as Original Medicare in addition to the tailored benefits. To enroll in an SNP plan, Medicare beneficiaries must have the condition or be in the situation that the plan is designed for.
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 Prescription Drug Coverage is known as Medicare Part D. Many Medicare Advantage plans include drug coverage, especially HMO and PPO plans. Some of these plans may charge a higher or separate premium for prescription drug coverage. Stand-alone Part D prescription drugs plans are available in Michigan but can’t be purchased by people enrolled in HMO or PPO plans, or they will be automatically disenrolled from Medicare Advantage and returned to Original Medicare. PFFS plans are less likely to include prescription drug coverage and people on these plans can usually purchase a stand-alone plan.
Medicare Advantage can offer seniors some appreciable health care benefits, but it can be difficult to understand the different plans, what’s included in each option and how to enroll. The variety of options can leave seniors confused about which Medicare plan best meets their needs and financial circumstances. Below are some state and local resources in Michigan that can help seniors navigate the system and maximize their benefits when enrolling in Medicare Advantage.
The Michigan Medicare/Medicaid Assistance Program (MMAP) provides education and counseling to help empower older adults and people with disabilities so that they can make informed health insurance decisions. Counselors are available to help seniors navigate health care options through a range of services, including reviewing insurance needs, enrolling in programs and explaining health plans. Combined, this helps seniors find a plan that provides the best coverage for their situation. MMAP counselors can also identify Medicare fraud and abuse and help seniors make relevant reports. The service is free for Michigan residents, and family members who live out-of-state can also contact counselors.
The Health Insurance Consumer Assistance Program (HICAP) offers free help to Michigan residents who need assistance with their health insurance. Seniors can receive assistance with finding a health care plan, switching plans and filing complaints. Additional information is available on the HICAP website, including information about health insurance for people with Medicare, long-term care insurance and Medicare supplements.
Elder Law of Michigan (ELM) is a nonprofit organization created to promote and protect the rights, economic stability and health of older adults. ELM provides education, advocacy and professional services. It runs Michigan’s Coordinated Access to Food for the Elderly (MiCAFE), which assists seniors to apply for a range of government benefits, including Medicare. ELM can also provide eligibility information for a range of health care programs including Medicaid, the Medicare Savings Program and Medicare Extra Help Part D.
Seniors can call 877-664-2233 to find their nearest MiCAFE Network site for assistance with applications. For other services and information about advocacy, ELM can be reached at 866-400-9164.
The Senior Alliance is a local Area Agency on Aging for southern and western Wayne County. It provides a range of services for older adults in the area, including the Information and Assistance Call Center. This free service connects seniors with Information Services Specialists who can provide answers to questions on a range of topics, including Medicare and Medicaid. Specialists assess the needs of callers and provide accurate information, as well as referrals to programs and services available in The Senior Alliance service area.
Information Services Specialists can be reached by calling 800-815-1112. The service is available Monday to Friday, from 8:30 a.m. to 4:30 p.m.
The Kalamazoo County Older Adult Services Division is the Area Agency on Aging for Kalamazoo County. The agency offers programming that helps older adults access services and provides support, advocacy and more. The Information & Assistance program has clinical social workers available to provide free, unbiased assistance to seniors and their caregivers. These social workers can evaluate needs, provide options for support and assist in navigating care and benefit programs. The program also has up-to-date information on health insurance programs such as Medicare, and can refer seniors to other resources.
The Valley Area Agency on Aging provides advocacy, action and information about the care of the elderly in Genesee, Lapeer and Shiawassee counties. Its Information & Assistance program makes certified resource specialists available to provide information about resources in the area. The service is available to older adults aged 60 and over, persons with disabilities and family caregivers, and it is free of charge. Information is available on a range of different topics, including Medicare and Medicaid. A listing of resources, information and tip sheets can be mailed to callers. The Valley Area Agency on Aging is HIPAA compliant, so any information provided is confidential.