Page Reviewed / Updated - May 16, 2020
Medicare Advantage plans, also called Medicare Part C, are offered through private insurance companies approved by the federal government to provide Medicare coverage. These plans must provide the same level of coverage as Part A and Part B Original Medicare offered by the federal government. Coverage may also include Part D, prescription drug coverage, and extra benefits, such as wellness programs or routine dental, vision or hearing care. Insurance carriers decide how much members pay for covered services, not the government, so the cost for Medicare Advantage plans vary.
A majority of the 64 million people on Medicare nationwide were covered by traditional Medicare in 2019, according to the Kaiser Family Foundation. However, 34% of Medicare beneficiaries opted for a Medicare Advantage plan. The popularity of Medicare Advantage fluctuates significantly among U.S. states and territories, with Puerto Rico at 71% enrollment and Alaska at only 1%. In comparison, New Jersey has an enrollment rate of 28%, which is notably less than the neighboring states of Pennsylvania and New York where enrollment rates are 41% and 39%, respectively.
Several insurance carriers offer various Medicare Advantage plans to New Jersey seniors. The plans offered are primarily HMOs and PPOs, with a few HMOPOS and even fewer PFFS, SNP and MSA plans from a limited number of providers. This guide covers the types of plans available in New Jersey, plus enrollment and eligibility requirements and prescription drug coverage. It also includes state and local resources that offer Medicare counseling to help New Jersey seniors understand their options and how to enroll.
There are several types of Medicare Advantage plans available to New Jersey seniors, but options vary based on the member’s county of residence. Medicare Advantage plans in New Jersey include Health Maintenance Organization and Preferred Provider Organization plans, along with Health Maintenance Organization Point of Service, Private-Fee-For Service, Medical Savings Accounts and Special Needs Plans.
Health Maintenance Organizations (HMO)
HMOs require participants to choose a primary care provider within the plan’s network, and members need referrals from PCPs to see specialists. While these plans tend to have lower premiums, the strict network rules limit flexibility. Members usually have to pay the full cost of care received from non-network providers, but exceptions are made for emergency services. Using in-network providers offers the lowest out-of-pocket expense to members.
Health Maintenance Organization - Point of Service (HMO-POS)
HMO-POS plans work the same as traditional HMO plans, but they offer a more flexible network in exchange for higher monthly premiums and co-pays. Plan members can go outside the HMO network under certain circumstances by paying additional fees. Some HMO-POS plans also cover routine health care received from non-network providers when traveling outside the network, making these plans a good choice for seniors who travel frequently.
Preferred Provider Organizations (PPO)
PPOs offer more flexibility and usually have higher premiums than HMOs. PPO members aren’t required to choose a primary care provider, and these plans typically cover part of the cost for care received from non-network providers. However, members receive the lowest co-pay and coinsurance rates when they stick to network providers and facilities. Unlike many HMO plans, PPOs typically have a deductible, but referrals from primary care doctors aren't required for members to see specialists.
Private-Fee-For Service (PFFS)
PFFS plans let members choose their own health care providers and hospitals, but out-of-pocket expenses tend to be higher than other Medicare Advantage plans. Some PFFS plans have a provider network, and members can see any providers they choose from within the network. Plans without a network allow members to see any Medicare-approved provider who agrees to the payment terms set by the plan. Insurers that offer PFFSs decide how much they will pay providers for services and how much members pay, instead of these amounts being set by Medicare.
Medical Savings Account (MSA)
MSAs work similarly to Health Savings Accounts. These plans have a high deductible, which members must meet before the plan begins covering their health care costs. However, this is combined with a special health savings account, which the plan makes deposits into annually from monies received from Medicare. Plan members pay for health care services from this account until their deductible is met.
Special Needs Plans (SNP)
SNPs limit membership to those with special needs, so not all Medicare recipients qualify for these types of plans. Dual Eligible SNPs cover seniors eligible for both Medicare and Medicaid and Institutional SNPs cover members in certain institutions, typically nursing homes. Chronic Condition SNPs are strictly limited to beneficiaries with specific chronic or disabling illnesses or diseases, such as diabetes or end-stage renal disease.
SNPs may charge a monthly premium in addition to a Medicare Part B premium, potentially making costs higher than other Medicare Advantage plans. However, SNPs tailor benefits, health providers and drug coverage to fit the specific needs of the members served. Generally, members must get their care from doctors and hospitals within the plan’s network and need a referral to see a specialist.
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 Advantage plans that offer prescription drug coverage may require a higher or completely separate monthly premium. Medicare Advantage plans that include prescription drug coverage are typically referred to as MA-PDs, but not all plans in New Jersey offer prescription drug coverage. Each of the different types of Medicare Advantage plans have specific rules regarding prescription drug coverage. Most HMOs and PPOs include a drug plan, as do PFFS plans, and all SNPs include prescription drug coverage by law.
Medicare Advantage HMOs and PPOs without prescription drug coverage don't allow plan members to sign up for a separate Part D prescription drug plan. Doing so results in the member being unenrolled from their Medicare Advantage plan. In contrast, PFFS plans that don't include prescription drug coverage allow members to sign up for Medicare Part D without losing their Medicare Advantage plan.
The cost of adding drug coverage to a Medicare Advantage plan and the specific drugs covered vary, but seniors with limited income may qualify for Extra Help to cover prescription drugs. New Jersey seniors may also qualify for state prescription drug assistance programs to reduce out-of-pocket costs, including deductibles, "donut hole" coverage gaps and co-insurance. This assistance is available to eligible seniors enrolled in Medicare Part D prescription drug plans, including Part D coverage that’s part of a Medicare Advantage plan.
Medicare is an invaluable program for older adults in need of health insurance coverage, but many seniors don’t understand how the program works or how to sign up. Others feel overwhelmed by the complex applications and enrollment process. Various New Jersey organizations offer counseling and guidance to help eligible seniors understand the different plans, coverage options, benefits, premiums, deductibles and other elements of the Medicare Advantage program. These Medicare counseling services are usually free of charge, including those on the following list of state and local resources in New Jersey.
The New Jersey Department of Human Services Division of Aging Services provides free assistance for New Jersey Medicare beneficiaries through its Senior Health Insurance Assistance Program. This statewide program utilizes trained counselors who provide information and assistance about Medicare and Medicare Advantage options, benefits, claims and supplement policies, including Medigap. Counselors never provide legal advice or endorse any specific insurance plan, product, agent or company, but supply the information seniors need to make their own decisions. Assistance may also include information about prescription drug coverage, evaluation of specific health insurance needs and help completing Medicare enrollment and health insurance claim forms.
For Medicare counseling and general aging services questions, call the State Health Insurance Assistance Program toll free at 1-800-792-8820 or search for your local SHIP office online.
The State of New Jersey Department of Human Services Division of Aging Services also administers the Area Agencies on Aging (AAAs) and the Aging & Disability Resource Connection. Each of New Jersey’s 21 counties have a dedicated AAA to serve older adults, which also operates the ADRC program in each county. Together, these programs ensure seniors and adults with disabilities have easy access to information about long-term care. Services include providing information about Medicare, Medicare Advantage, Medicaid, Medicare Part D prescription drug coverage and long-term care. Counseling and assistance about Medicare eligibility and application processes are also provided.
Get more information about ADRC services by calling 1-877-222-3737 toll free or search for your local Area Agency on Aging online.
The Passaic County Department of Senior Services, Disabilities and Veterans' Affairs in Totowa, New Jersey, acts as the county's State Health Insurance Plan Coordinator and Area Agency on Agency, and operates the Aging & Disability Resource Connection that assists Medicare beneficiaries in and around Passaic County. New Jersey residents receive free Medicare counseling, assistance with benefits screening, entitlement consultations and information about Medicare Advantage, Medicare Part D and Medigap coverage. Staff can also help beneficiaries qualify for the Pharmaceutical Assistance to the Aged & Disabled program, which helps eligible seniors aged 65 or older and disabled individuals save money on prescription drug costs.
To inquire about any of the services provided by the Passaic County Department of Senior Services, Disabilities and Veterans' Affairs call 973-569-4060 or send an email to [email protected].
The Sussex County Division of Senior Services operates the Aging & Disability Resource Connection in Newton, New Jersey. Medicare beneficiaries throughout the ADRC's service area receive help with their health insurance, including Medicare, Medicare Advantage, Medicaid and other insurance options. Assistance is also available with Medicare Part D prescription drug plans, special benefits under the Medicare Improvements for Patients and Providers Act, Medigap and Medicare billing issues. All programs are free and available for seniors and adults with disabilities, regardless of income.
For more information about any of the programs offered by the Sussex County Division of Senior Services, call 973-579-0555 or email [email protected].
Medicare beneficiaries feeling overwhelmed by health and prescription insurance plan choices can find assistance at the Cape May County Department of Aging & Disability Services in Rio Grande, New Jersey. This program offers free, one-on-one counseling from experienced State Health Insurance Assistance Program counselors who can help Medicare beneficiaries make informed health care decisions and choose the right coverage to meet their needs. SHIP counselors also provide assistance with Medicare Part B premium savings, Medicare Advantage plans, Medicare Part D prescription plans and Medigap policies. They can also answer questions about claims and billing issues, and help seniors apply for state prescription assistance programs.
Schedule Medicare counseling or ask health insurance-related questions by contacting Aging & Disability Services in Cape May County at 609-886-2784.
Middlesex County seniors with questions about Medicare insurance plans, benefits, claims, supplemental policies or long-term care insurance can receive free assistance and counseling through the Middlesex County Office of Aging & Disabled Services' State Health Insurance Program. Trained SHIP counselors provide help to Medicare beneficiaries with any type of question or problem related to Medicare, Medicaid, Medicare Advantage, Medicare Part D or other health insurance coverage and benefits. Counselors can also assist seniors in evaluating their health insurance needs, dealing with Medicare claims and applying for or changing Medicare coverage or prescription drug coverage, as well as help low-income seniors and disabled persons save money on prescription costs and Medicare premiums.
For a counseling appointment or assistance with any Medicare question, call SHIP counselors from the Middlesex County Office of Aging & Disabled Services directly at 732-745-3295. Jewish Family Services also has trained SHIP counselors contracted to help the Middlesex County office in assisting seniors with the Medicare program. Call their Milltown office at 732-777-1940 or their Monroe Township office at 609-395-7979.