Page Reviewed / Updated - May 18, 2020
Medicare Advantage plans must provide the same level of coverage as Original Medicare, including hospital insurance (Part A) and medical insurance (Part B). The only exception is hospice care, which is always covered by Original Medicare Part A no matter what type of Medicare health plan a participant has. Only Medicare-approved private insurance companies can offer Medicare Advantage plans, while Original Medicare is provided directly by the federal government. Besides Parts A and B coverage, Medicare Advantage plans, sometimes called Part C, often include extra benefits like prescriptions drug coverage (Part D), dental and vision care or wellness programs.
In 2019, 64 million people were enrolled in Medicare nationwide, according to the Kaiser Family Foundation. Most of these beneficiaries had traditional Medicare, but 34% of Medicare participants were enrolled in Medicare Advantage plans. The number of enrollees in Medicare Advantage plans vary significantly between states, and Oklahoma falls on the low side with 20% enrollment. The neighboring state of Texas has a much higher enrollment rate of 36%, while enrollment in Kansas is nearly comparable at 17%.
Oklahoma seniors interested in enrolling in Medicare Advantage have a choice of several insurance providers offering a variety of plans. This guide covers the five types of plans available in Oklahoma, which include HMOs, PPOs, PFFSs, SNPs and MSAs. It also provides details on enrollment and eligibility requirements, prescription drug coverage and state and local resources that can help Oklahoma enrollees decide which Medicare Advantage plan is right for them.
Several insurance carriers offer Medicare Advantage plans in Oklahoma, but not all of the plans offered may be available in every county. Options for Oklahoma seniors may include Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private-Fee-For Service (PFFS) plans, Medical Savings Accounts (MSA) and Special Needs Plans (SNP).
Health Maintenance Organizations (HMO)
HMOs usually have the lowest premiums compared to other Medicare Advantage plans, but in exchange, plan participants must adhere to strict network rules. Members must choose a primary care provider and can only see a specialist after receiving a PCP referral. If a member doesn’t receive health care services from in-network HMO providers and facilities, they may be required to pay the entire cost for care received. Exceptions may be made for emergencies at out-of-network facilities, especially those occurring outside the normal service area.
Preferred Provider Organizations (PPO)
PPOs offer more flexibility to see any health care provider within the plan’s network. Plan members aren’t required to choose a primary care provider or get a referral from a PCP to see a specialist or out-of-network providers. However, co-pay and coinsurance rates are lower when using preferred providers within the network. The flexibility to see any doctor or provider that accepts Medicare often comes with higher premiums compared to other Medicare Advantage plans. PPOs usually also require a deductible, unlike HMOs that may offer plans with comparatively low or no deductibles.
PFFS are fee-for-service plans offered by private companies that decide how much they pay providers, and how much the members pay for health care services, instead of the Medicare program deciding. Members may go to any Medicare-approved health care provider or hospital that accepts the plan’s payment terms, but the plan may require members to stay within a network of providers. PFFS plans that include a network require network providers to always treat plan members, even if the provider has never seen the member before. Participants can sign up for prescription drug coverage with the PFFS plan, if it’s offered, or sign up for a separate Medicare Part D prescription drug plan without losing their Medicare Advantage plan.
Special Needs Plans (SNP)
SNPs aren’t available to all Medicare participants, but instead cater to three distinct types of members with special needs. Chronic Condition SNPs, listed as C-SNPs by insurance carriers, tailor benefits, provider choices and drug plans to meet the unique needs of beneficiaries with chronic or disabling illnesses or diseases, such as congestive heart failure or diabetes. Institutional SNPs, listed as I-SNPs, cater to members living in certain institutions, such as nursing homes. Dual Eligible SNPs, called D-SNPs, are specifically for members eligible for both Medicare and Medicaid. Currently, there’s only one SNP available in Oklahoma, in the greater Ardmore area.
Medical Savings Account
Similar to Health Savings Account plans found outside Medicare, MSAs combine a high deductible health plan with a special health savings account. Medicare provides an amount annually to cover a member's health care, and the MSA plan deposits a portion of this money into the member’s savings account. The plan itself doesn’t cover a member's health care costs until they meet the high annual deductible. Until then, members may use money from their savings account to pay for health care services. Members may choose their own health care providers and must sign up for Medicare Part D for prescription drug coverage, which isn’t covered by MSA plans.
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.
Not all Medicare Advantage plans in Oklahoma include prescription drug coverage, and the coverage cost and drugs covered vary between the plans offering drug coverage. While not required, many HMOs and PPOs include prescription drug plans, but may require a higher monthly premium or even a separate monthly premium for this benefit. If the HMO or PPO plan doesn’t provide prescription drug coverage, members aren't allowed to sign up for separate coverage through a Medicare Part D provider or they will lose their Medicare Advantage plan. PFFS plans allow members to join a separate Medicare prescription plan if their plan doesn’t include drug coverage. SNPs are required by law to provide prescription drug coverage. If a Medicare-participant doesn’t sign up for a Medicare drug plan when they first become eligible, joining one later may result in a late enrollment penalty. Seniors with limited income may qualify for extra help to cover prescription drugs.
Older adults greatly benefit from health insurance coverage through the Medicare program, but some seniors don’t understand how to sign up or how the program works. Medicare-eligible seniors who are overwhelmed by the complex application and enrollment process can find help through various Oklahoma organizations. Personalized Medicare counseling is usually free and can help qualified Medicare recipients navigate the various coverages, benefits, deductibles, premiums, co-payments, coinsurances and other elements of the Medicare program. Listed below are some of the state and local resources in Oklahoma designed to help guide seniors through the Medicare system and make the most of their health care coverage.
The free Medicare Assistance Program offered statewide through the Oklahoma Insurance Department includes the Senior Health Insurance Counseling Program, known as SHIP, and the Senior Medicare Patrol, known as the SMP. Certified MAP counselors are trained annually to counsel Medicare beneficiaries and assist them with comparing Medicare Advantage plans, choosing a Medicare Part D prescription drug plan and unraveling Medigap policies and Medicare Supplemental Insurance plans. Alternatively, the SMP utilizes volunteer advisors who help Oklahoma seniors learn how to protect themselves from health care fraud and how to read their Medicare Summary Notices to detect and report discrepancies.
The Oklahoma Insurance Department Assistance Division handles all types of inquiries. You can contact the Oklahoma City office directly at 405-521-2828, or the Tulsa office at 918-295-3700 or call 800-522-0071 toll free from anywhere in Oklahoma. You can also request assistance online.
Non-profit organizations operate the Senior Health Insurance Counseling Program, which is dedicated to informing Oklahoma seniors about Medicare and other health insurance issues. Counselors provide accurate, objective assistance and advocacy relating to Medicare, Medicaid, Medicare Advantage, Medicare supplements, long-term care and other health coverage plans for current and future Medicare beneficiaries and their representatives. This service is free of charge and available throughout the state.
Local callers can reach the Senior Help Line at 405-521-6628 for assistance with Medicare counseling, or call the helpline toll free at 800-763-2828.
The Oklahoma State Council on Aging serves in an advisory capacity to the Oklahoma Department of Human Services’ Aging Services Division and acts as an advocate for older Oklahomans. As part of this program, 11 Area Agencies on Aging exist throughout the state to assist Medicare beneficiaries with one-on-one counseling and help review Medicare options, including Medicare Advantage plans, Medicare Part D enrollments, the Low Income Subsidy, SMP Medicare Fraud Awareness and other health insurance issues.
Call the Senior Info-Line for information and assistance toll free at 800-211-2116, or locate your local Area Agency on Aging office online.
Through its Medicare Assistance Program, LIFE Senior Services provides assistance with Medicare, Medicare Advantage, Medicare supplements and other health coverage options for current and future Medicare beneficiaries and their representatives. LIFE serves seniors in northeastern Oklahoma throughout a region consisting of 17 counties without charge.
Trained counselors help Medicare beneficiaries compare, select and enroll in the Medicare plans that best fit their needs through personalized counseling. LIFE also offers educational seminars throughout the year to help Medicare beneficiaries understand and acquire the services they need. Medicare Part D assistance clinics are held annually from October through December to help seniors compare their drug plan options. During these clinics and throughout the year, LIFE also assists those wanting to apply for the Extra Help program, which can significantly reduce the cost of prescription medications for low income seniors.
Reservations are required for Medicare Part D clinics, and appointments are necessary for counseling. Call LIFE Senior Services at 918-664-9000, ext. 1189, for more information or to make reservations/appointments. You can also email your questions and requests to [email protected]g.
As an Area Agency on Aging, the Southern Oklahoma Development Association offers a Medicare assistance program as a free referral service to Oklahomans aged 60 and over seeking information and/or assistance. Service areas include the counties of Atoka, Bryan, Carter, Coal, Garvin, Johnston, Love, Marshall, Murray and Pontotoc. The Southern Oklahoma Development Association also operates the Senior Health Insurance Counseling Program in southern Oklahoma, providing advocacy, assistance and counseling to senior residents who are current or soon-to-be Medicare beneficiaries.
Through this program, seniors get their Medicare questions answered and receive assistance with Medicare plans, Medicare Advantage, Medicare supplements, Medicaid, long-term care and other health-related plans. This agency also oversees the area’s Senior Medicare Patrol to help beneficiaries protect themselves from health care fraud, and learn to monitor what has been paid by Medicare or Medicaid on the beneficiary’s behalf. As part of the Medicare Improvements for Patients and Providers Act Program, the agency also conducts outreach programs and helps enroll low-income Medicare-approved seniors into Medicare Saving Programs and the Low Income Subsidy for Medicare Part D.
Seniors residing in any part of the service area may schedule Medicare counseling with the Southern Oklahoma Development Association in Durant by calling the Senior Information Line toll free at 800-211-2116.
The Long Term Care Authority of Enid offers senior Medicare counseling as an Area Agency on Aging and Oklahoma Insurance Department’s Medicare Assistance Program provider. The LTCA of Enid provides certified counselors to answer Medicare and other health insurance-related questions. It also offers free Medicare Part D prescription plan comparisons and assistance with enrollment or coverage changes during open enrollment periods. Counselors will also help Medicare beneficiaries determine if they qualify for the Extra Help program, which helps pay Medicare Part D prescription drug costs. Reduced costs for qualified beneficiaries may include lower prescription co-payments, annual deductibles and monthly premiums.
You may request Medicare counseling over the phone or in person, and complete an application for the Extra Help program over the phone. Schedule an appointment or request more information by calling LTCA of Enid staff at 580-234-7475, or contact the Director of the Area Agency on Aging via email.
Through Opportunities, Inc. at Northwestern Oklahoma Community Action, seniors in Alfalfa, Beaver, Beckham, Blaine, Cimarron, Custer, Dewey, Ellis, Harper, Kingfisher, Major, Roger Mills, Texas, Washita, Woods and Woodward counties receive assistance with health services through four insurance and prescription assistance programs. These programs include the Senior Health Insurance and Medicare Improvements for Patients and Providers programs to provide counseling services to Medicare beneficiaries in rural areas, and promote new Medicare prevention and wellness benefits. Others are the Senior Medical Patrol to help seniors prevent Medicare fraud, and Rx for Oklahoma, a referral program that connects income eligible individuals with pharmaceutical companies that offer free or low-cost medications.
For more information about the SHIP, MIPPA, SMP or Rx for Oklahoma programs, contact Opportunities, Inc. by calling the main office in Watonga at 580-623-7283, the Clinton office at 580-323-4373, the Guymon office at 580-338-7878 or the Woodward office at 580-256-2899 or 844-290-3914.