Page Reviewed / Updated - May 12, 2020
Medicare Advantage plans give members additional levels of coverage that aren't provided through Original Medicaid, such as dental, vision and prescription drug coverage. MA plans are also known as Part C; they cover all of the benefits available in Part A and B by default, and they usually also include Part D. Private insurance companies are paid by Medicare on behalf of the member and are responsible for the provision of benefits.
According to a 2019 report from the Kaiser Family Foundation, one-third of Medicare members throughout America are served by a Medicare Advantage plan. Nevada has a slightly higher rate of enrollment in MA plans at 35%, which is fairly typical in this area of the country. The popularity of these plans is higher in some neighboring states, such as Oregon, California and Arizona, where usage rates are 42%, 40% and 38%, respectively. These numbers have been steadily rising over the last two decades and the upward trend is expected to continue.
There are multiple options available for Medicare Advantage in Nevada with greatly different levels of coverage, but they may not all be available in every service area across the state. The most popular types of MA plans are the Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO), as well as Special Needs Plans (SNP), which are tailored to the individual. This guide covers the main types of Medicare Advantage plans available in Nevada and includes additional state and local resources that can help residents decide which option is the most appropriate.
Medicare Advantage plans are available to Nevada residents who currently have Original Medicaid (Part A and B) and who live within the service area of the particular plan. The cost may be higher or lower from county to county, and some plans are unavailable in certain counties, so it's important to research all options.
Health Maintenance Organizations (HMO)
This type of plan is generally more restrictive in the options available to its members, although the cost is almost always lower than the comparable alternatives. Health Maintenance Organization plan members must seek care from within a network of approved health care providers, such as doctors, specialists, hospitals and other facilities, except in the case of emergency and urgent care. Specialist care requires a referral from the primary care doctor, in most cases. If a member of a HMO plan seeks care from providers outside of the network, the member may be responsible for the full cost of care.
Preferred Provider Organizations (PPO)
Preferred Provider Organization plans in Nevada are similar to HMOs — with a predefined network of approved health care providers available to the member — although they're slightly more accommodating of out-of-network care. PPO plan members can seek care from any provider, and they don't require a referral to see a specialist. However, this additional flexibility over HMO plans comes with additional costs to the member.
Special Needs Plans
Special Needs Plans are a type of Medicare Advantage plan that is tailored to people with certain health care needs, such as cancer, dementia or other chronic conditions, and for people with low incomes. This includes people who are institutionalized, such as living in a nursing home, and people who have both Medicare and Medicaid (Dual Eligible). SNP plans provide all of the benefits available through other Medicare Advantage plans and cover additional services that are appropriate for the specific needs of the member. These plans are also required to provide prescription drug coverage (Part D).
Medical Savings Account
This type of coverage provides members with a high-deductible Medicare Advantage Plan combined with a Medical Savings Account. The specific deductible is different from each provider in Nevada, but it's always higher than the more common alternatives. However, the plan transfers funds to the member's Medical Savings Account each year, which can be used to cover costs until the deductible has been reached. MSA funds can be used to pay any health care provider and can even be used to pay for services that aren't covered by Medicare.
Private Fee-for-Service plans may use a network of approved health care providers, such as those used in HMO and PPO plans, and members incur lower costs when receiving care from these providers. The provider must agree to the PFFS conditions in the plan before treatment or the provision of services, and they bill the private health insurance company responsible for the PFFS plan. Members of a PFFS plan receive an additional ID card, which must be used at the point of care each time, instead of their usual Medicare card.
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.
Most Medicare Advantage plans offered in Nevada also include prescription drug coverage. All of the available Special Needs Plans in the state are required to include Medicare prescription drug coverage, and most Health Maintenance Organizations, Preferred Provider Organizations and Private Fee-for-Service plans also include it. Medical Savings Account funds may be used to pay for prescription drugs. Members of a PFFS plan that doesn't cover prescription drugs are permitted to enroll in a Medicare Prescription Drug Plan (PDP). However, members of an HMO or PPO that doesn't cover prescription drugs cannot enroll in a separate Medicare plan. Coverage is provided by private companies, which set their own premiums and deductibles and provide a list of prescriptions to be covered under the plan.
Nevada residents have more options than most when it comes to Medicare Advantage, which can make the enrollment process confusing and difficult. Fortunately, seniors who need help choosing the right plan for their specific situation can reach out to trusted experts on the subject. We've compiled a list of various state and local resources that may be of assistance in getting the most benefits out of Medicare Advantage.
Nevada's Department of Health and Human Services offers an information and counseling program known as the State Health Insurance Assistance Program (SHIP). This program gives Medicare members access to a network of volunteers around the state who provide one-on-one assistance and counseling on many issues related to aging, insurance and the variety of Medicare options available. Counselors can help seniors assess which plan is the most appropriate for their needs, including eligibility and the appeal process, as well as assistance enrolling in a Prescription Drug Plan (Part D), if needed.
The Office for Consumer Health Assistance is another resource that helps Nevada residents access health care and prescription drugs and understand their rights under various plans and policies. This includes managed care, insurance provided by an employer, the Employee Retirement Income Security Act, Medicare and Medicaid. State residents who aren't insured, or are underinsured, can also receive assistance and access to resources from the OCHA.
Seniors can call the OCHA during regular business hours at 1-702-486-3587 or toll-free at 1-888-333-1597. Alternatively, in the case of specific issues and complaints regarding a health insurance company or hospital, seniors can print and fill out a request for assistance form.
Nevadans with low-incomes may benefit from the Medicare Savings Programs available in the state, which help people gain and maintain access to health care by paying their Medicare premiums and co-pays. As of 2020, these programs can help eligible residents save at least $104.90 per month. Eligibility is split into four categories that are largely based on income, and this eligibility category determines which benefits are provided. The specific income and resource limits for each category are listed on the website.
The Aging and Disability Services Division operates various resource centers around the state under the Nevada Care Connection program. The purpose is to help Nevadans find out which options are available for them in matters related to aging, disabilities and insurance. Caregiver support and veterans services are also available. Nevada Care Connection staff can help make health care more accessible and individualized by providing information tailored to the individual and helping them connect with appropriate governmental agencies and health care providers.
Visit the Nevada Care Connection website to find the closest resource center, as well as local phone and email contacts.
The Senior Medicare Patrol is made up of volunteers in local communities who help seniors and their families and caregivers detect and report Medicare fraud and keep their personal information secure. SMP staff give presentations at seniors fairs and community events.