Instead of participating in Original Medicare Parts A and B for hospital and general health care coverage, Missouri seniors can opt to enroll in Medicare Advantage, also known as Medicare Part C. Medicare Advantage provides seniors with a wide selection of plans through private insurers, which unlike Original Medicare, can include additional benefits such as vision, hearing, dental and prescription drug coverage. Participants in Medicare Advantage pay varying costs and receive differing coverage levels depending on the particular plan they select. Unlike Original Medicare where all participants receive the same level of coverage, Medicare Advantage participants can benefit from more comprehensive coverage tailored to their needs.
According to the Kaiser Family Foundation, approximately 39% of Missouri seniors enrolled in Medicare participate in a Medicare Advantage plan. This is an equivalent rate to the national average, and a higher percentage than many of the surrounding states. The closest states with higher rates of Medicare Advantage enrollment are Minnesota and Tennessee. States directly west of Missouri, such as Kansas and Nebraska, have lower rates of enrollment at 20% and 19%, respectively.
In this guide, we provide an overview of the different types of Medicare Advantage plans offered in Missouri, which include HMOs, PPOs, PFFS, MSAs and SNPs. Plans can range significantly in cost and coverage levels, allowing seniors to shop for a plan most amenable to their unique needs. Below, we also discuss prescription drug coverage options for Medicare Advantage participants, detail enrollment information and provide a list of resources seniors can access to better understand their health care options and ensure they select a plan that works for them.
Multiple Medicare Advantage plan types are offered throughout Missouri. Depending on what’s available in their area and their needs, Missouri Medicare beneficiaries may be able to choose from HMOs, PPOs, PFFS and MSA plans and SNPs.
Health Maintenance Organizations (HMOs)
Seniors enrolled in an Health Maintenance Organization, or HMO, receive their health care benefits from a preferred list of network providers. If plan participants venture outside of this network to receive services from an out-of-network provider, their medical care costs will likely not be covered. HMOs typically require participants to select a primary care physician (PCP) whom they must see for regular medical visits. Specialist referrals are also typically required. While costs depend on the individual plan selected, HMOs are frequently the most affordable type of Medicare Advantage plan.
Preferred Provider Organizations (PPOs)
While seniors pay more to enroll in a Preferred Provider Organization, or PPO, plan than an HMO, these plans offer participants a little more flexibility. PPOs have a list of in-network providers from whom participants can receive full coverage, but the plan will typically also pay some portion of the costs if participants receive services from an out-of-network provider. Additionally, PPOs do not require seniors to designate a PCP, nor do they require referrals for specialist visits.
Private Fee-For-Service Plans (PFFS)
PFFS plans typically offer seniors even more flexibility to decide which providers they would like to see. Some PFFS plans have a network of providers, and some do not, but in both cases, participants may see any provider that agrees to the plan’s payment terms and receive full coverage. PFFS plans generally have higher monthly premiums than HMOs or PPOs, and not all providers are willing to accept the payment terms of these plans.
Medical Savings Accounts (MSAs)
Some Missouri seniors may be able to enroll in a high-deductible Medicare Advantage plan called a Medical Savings Account (MSA). These plans deposit money into a savings account, and plan participants can then use those funds to pay for any health care services they receive until they reach the plan’s yearly deductible and their coverage kicks in.
Special Needs Plans (SNPs)
Special Needs Plans, or SNPs, are plans restricted to and provide tailored benefits for certain groups of people. In Missouri, nursing home residents, seniors with certain disabilities and individuals eligible for both Medicare and Medicaid may qualify for an SNP designated for their specific groups. Like HMOs, these plans have a network of preferred providers that participants must use to receive coverage.
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.
Missouri seniors enrolled in a Medicare Advantage plan may receive prescription drug coverage directly through their plan as a bundled Medicare Advantage-Prescription Drug (MA-PD) plan. Many HMOs and PPOs include this option. SNPs are federally mandated to include prescription drug coverage, and seniors with MSAs may opt to enroll in a separate Medicare Part D plan that specifically covers prescription drugs. PFFS plans may include prescription drug coverage or allow participants to enroll separately in a Medicare Part D plan. MA-PD plans may include prescription drug coverage in their standard monthly premium, while seniors with stand-alone Part D plans would need to pay premiums for both their Medicare Advantage and Part D plans.
Numerous resources are available throughout Missouri, both at the state and local level, to help seniors better understand their Medicare Advantage options and the sign-up process. Because we know that sifting through Missouri’s many plan types and learning about individual plan rules, benefits, costs and enrollment can be a challenge, we’ve included information about several of these resources below.
Community Leaders Assisting the Insured of Missouri, or CLAIM, is Missouri’s State Health Insurance Assistance Program (SHIP). CLAIM has over 450 partners and trained and certified volunteer Medicare counselors who provide confidential Medicare benefits counseling services. Counselors answer questions, educate seniors about their Medicare options, help them apply for and enroll in Medicare plans, file claims, organize health care bills and make appeals. Additionally, counselors can help seniors apply for available programs that may help pay for Medicare Parts B and D. The CLAIM website also has pages explaining the state’s Medicare options, supplements and related programs.
The Missouri SMP, or Senior Medicare Patrol program, works to protect Missouri Medicare and Medicaid participants from health care fraud. Program volunteers provide Medicare beneficiaries with one-on-one counseling services, education and outreach designed to empower seniors to recognize, prevent and report any type of health care abuse, mistakes or fraud. Volunteers can help seniors recognize errors on their medical bills and protect themselves from Medicare-related identity theft.
Seniors can call the SMP hotline at 888-515-6565, call the program’s main line at 660-747-5447 or email [email protected]. They can also mail an inquiry to 106 W. Young, P.O. Box 1078, Warrensburg, MO 64093.Email
The Missouri Department of Health and Senior Services website has a page with a list of links to various Medicaid and Medicare resources. Seniors can visit this site to find answers to frequently asked questions about open Medicare enrollment, learn about Medicare Advantage and Medicare supplemental Medigap policies, get updates on the latest Medicare news and more.
The Missouri Department of Insurance is a state agency dedicated to helping residents understand their insurance options, consumer rights and the laws regulating insurance. Seniors can visit the website to find information about Medicare and Medigap policies, long-term care insurance and other senior resources within the state. Insurance consumers can visit the site to learn how to file complaints and appeal an insurance company’s denial of a claim. The website also has an insurance shopping tool to help consumers identify their needs and compare plans and costs.
To reach the Missouri Department of Insurance, seniors can call 573-751-4126, visit the office in person at 301 W. High St., Room 530 in Jefferson City or mail questions and inquiries to P.O. Box 690, Jefferson City, MO 65102-0690.
Area Agencies on Aging, such as Senior Age, are located throughout Missouri, and most have care coordinators available to help seniors enroll in Medicare plans and understand their benefits. Seniors unable to visit an office in person may be able to receive a home visit from a care coordinator to assess and discuss their needs. Missouri AAAs may also provide general benefits counseling, “New to Medicare” classes and comprehensive information about Medicare enrollment and related resources on their website.
A map of the coverage areas for Missouri’s 10 Area Agencies on Aging can be found on the Missouri Department of Health and Human Services website. The map lists the contact information for each agency, including its physical and web address and telephone number.Visit Website
VOYCE is an advocacy and resource nonprofit serving 21 counties in and around St. Louis. The organization’s mission is to help seniors and their loved ones receive high quality, long-term care. The website’s list of resources includes the national site to help Medicare recipients compare nursing homes, and it has a Medicare page linking to resources explaining recent Medicare changes, how to complete enrollment forms and more. Other services VOYCE offers include a helpline that connects callers to a licensed long-term care expert who can provide advice about Medicare and other financing options.