Medicare Advantage, also called Part C, is a type of comprehensive medical insurance offered through private insurance companies. This alternative to Original Medicare combines the benefits offered by Part A and B with various value-added services, such as dental, vision, hearing and prescription drug coverage. Medicare Advantage Plans are available to seniors across Ohio, although costs and coverage vary by provider and geographic area.
According to the Kaiser Family Foundation, Part C enrollment has more than tripled since 1999. Nationally, more than 22 million seniors are enrolled in Medicare Advantage plans. In the Buckeye State, 38% percent of Medicare beneficiaries have this type of coverage, and enrollment is close to 50% in some counties, which is moderately higher than the national average of 34%. Regional enrollment is typical of the Midwest and nearby states like Pennsylvania and Illinois.
Ohio seniors who are Medicare-eligible for the first time or want to change coverage can choose from more than 100 Medicare Advantage Plans from dozens of insurers. Options include Health Maintenance Organizations, local and regional Preferred Provider Organizations, Special Needs Plans, Private Fee-For-Service Plans and Medical Savings Accounts, and most include prescription drug coverage. This guide provides an overview of each type of plan as well as coverage options and potential costs. We’ve also included a list of state and local resources to help Ohio residents compare plans and select the best option for their needs.
Medicare Advantage is an umbrella term covering Medicare-approved, privately administered insurance plans that replace Part A and Part B benefits. In Ohio, seniors can choose from HMOs, PPOs, SNPs, PFFS plans and high-deductible MSAs.
Health Maintenance Organizations (HMOs)
With a Health Maintenance Organization, or HMO, members must visit in-network providers for most nonemergency medical services, excluding out-of-area urgent care or dialysis. In most cases, beneficiaries must select a primary care provider and request a referral before visiting a specialist. Contracts allow HMOs to provide in-network services with competitive co-pays. Some plans will reimburse other providers, but the out-of-pockets costs are usually substantially higher. While HMOs tend to offer lower premiums, members face more restrictions.
Preferred Provider Organizations (PPOs)
Like HMOs, Preferred Provider Organizations use a network of contracted health care professionals to deliver most services. However, PPOs give members more freedom. Beneficiaries don’t need a referral to visit a specialist, and most plans will cover out-of-network services at a reduced rate. Members don’t have to choose a primary care physician. Although premiums may be slightly higher, PPOs provide greater flexibility in and out of network and when traveling.
Special Needs Plans (SNPs)
Special Needs Plans, also called SNPs, serve Ohio seniors who are disabled or have substantial medical needs. SNPs are available to residents with specific medical conditions, such as dementia, chronic heart failure and end-stage renal disease. Nursing home residents and dual Medicare/Medicaid beneficiaries may also qualify for these plans. SNPs differ from HMOs and PPOs because they are required to cover prescription drugs. Additionally, plans may limit membership to specific populations.
Private Fee-For Service (PFFS)
Private Fee-For-Service Plans are another alternative available to some Medicare enrollees in Ohio. This option offers the greatest degree of flexibility, since most PFFS Plans don’t have provider networks. To use the coverage in a nonemergency, members can visit any provider who agrees to accept the plan’s predetermined rates. There are co-pays, and in some cases, providers are allowed to bill PFFS patients up to 15% more than the Medicare-approved amount. Additionally, these Medicare Advantage plans aren’t required to offer prescription drug coverage.
Medical Savings Accounts (MSAs)
A Medical Savings Account, or MSA, is a high-deductible, self-directed Medicare Advantage Plan that’s structured like a conventional tax-advantaged Health Savings Account. Insurers disburse a predetermined amount into each member’s account annually. These funds can be used to pay for qualified medical expenses at the beneficiary’s discretion. MSAs do not have co-pays or coinsurance, and they don’t pay for services directly until the deductible is satisfied. Additionally, MSA members must join a separate prescription drug plan. Annual disbursements and deductibles vary depending on the plan, and members must continue to pay their Part B premiums. MSAs are ideal for seniors who can afford higher out-of-pocket costs and want more control over their health care spending. Funds can also be used for nonmedical expenses, although taxes and penalties may apply.
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 in Ohio include prescription drug coverage as a value-added benefit. Seniors who are considering a Part C plan that doesn’t include this coverage must pay for medications out-of-pocket or maintain coverage through an employer. It’s important to note that a late-enrollment penalty may apply to individuals who have a lapse in creditable prescription drug coverage. To maintain a fair marketplace, government rules prevent seniors from enrolling in Part C and D simultaneously. In most cases, Medicare Advantage beneficiaries who join a PDP will be automatically disenrolled from Part C and returned to Original Medicare Parts A and B. With an MA-PD plan, drug coverage is typically included in the monthly premium.
Medicare provides valuable insurance coverage to Ohio seniors. However, it’s part of a complex government-regulated system with multiple components. From comparing coverage to enrolling and changing providers, choosing the right Medicare Advantage plan is an involved and highly individualized process. Fortunately, government agencies and local nonprofits provide a variety of resources to help seniors understand their options and make the best choice for their needs. Additional information about Medicare Advantage resources in Ohio is available below.
The Ohio Senior Health Insurance Information Program (OSHIIP) provides free one-on-one counseling to Medicare beneficiaries and caregivers statewide. Trained counselors and volunteers help residents compare Medicare Advantage Plans and other alternatives, including Medigap coverage and Part D Prescription Drug Plans. Experts can also provide additional information about financial assistance programs like Extra Help. Counseling services are available via OSHIP’s toll-free hotline. The agency also organizes webinars and hosts more than 1,400 outreach events. Every year, more than 260,000 consumers receive impartial advice through this award-winning program.
Low-income seniors may access a variety of benefits through the Ohio Department of Medicaid. This agency manages the Medicare Premium Assistance Program (MPAP), which helps qualifying individuals pay for their Medicare premiums, prescription drugs and out-of-pocket costs, including deductibles and/or coinsurance payments. Eligibility is based on the applicant’s income and assets.
The Ohio Department of Insurance is a regulatory agency and consumer protection bureau that licenses insurance agents, provides educational resources and investigates complaints. Residents can contact the ODI’s toll-free hotline for assistance with questions related to Medicare, Part D drug plans, long-term care insurance and all other policies.
UHCAN Ohio is a statewide coalition representing more than 20 regional consumer advocacy groups, including Ohio Consumers for Health Coverage. This organization focuses on influencing government policies, giving consumers a voice and ensuring that all Ohioans have access to affordable, quality medical care. The agency provides information about insurance enrollment, prescription drug assistance, Medicare Extra Help and insurance complaints.
The Central Ohio Area Agency on Aging (COAAA) provides a variety of resources to help seniors select the best Medicare plan for their needs. The organization hosts monthly workshops and has published a series of short, informative Medicare for Beginners videos that seniors can watch online anytime. Trained staff members provide insurance counseling to some 10,000 seniors in Delaware, Fairfield, Fayette, Franklin, Licking, Madison, Pickaway and Union counties.
Licensed social workers and OSHIP-certified experts provide personalized Medicare counseling at Cincinnati-based Jewish Family Service. Trained professionals help seniors of all faiths compare Medicare plans, including HMOs, PPOs and prescription drug coverage. Similar services are available for long-term care insurance, retiree health plans and Medicare supplements.
The Ohio District 5 Area Agency on Aging, Inc. (AAA) has served seniors in nine north-central Ohio counties for the past 45 years. Options counselors can answer insurance questions and help residents compare Part D prescription drug plans. The agency can also help low- and moderate-income seniors apply for Extra Help that can reduce their Part B premiums and prescription drug costs.
Ohio District 5 Area Agency on Aging serves seniors, caregivers and disabled adults in Richland, Ashland, Crawford, Huron, Knox, Marion, Morrow, Seneca and Wyandot counties. Residents can learn more online, by calling 1-800-860-5799 or by visiting the AAA office in Ontario.Visit Website
Located in southeast Ohio, the Buckeye Hills Regional Council has served area seniors for more than 50 years. The agency offers Medicare/Medicaid counseling, information and referrals. During Medicare open enrollment, seniors can sign up for a group workshop or schedule a one-on-one consultation. Certified staff members help residents apply for Medicare Extra Help benefits, including the Low-Income Subsidy and Medicare Savings Program. The center also connects seniors with financial assistance available through the Medicare Improvements for Patients and Providers Act of 2008.
The Buckeye Hills Regional Council serves seniors in Athens, Hocking, Meigs, Monroe, Morgan, Noble, Perry and Washington counties. For insurance counseling or information about other programs and resources, seniors can call 740-374-9436 or email the agency at [email protected].Email