Medicare Advantage gives seniors an alternative to the federal government’s Original Medicare (Medicare Parts A and B). Also called Medicare Part C or MA plans, Medicare Advantage is offered by private Medicare-approved insurance companies, and coverage and costs vary between providers. Some Medicare Part C plans include enhanced vision, hearing and prescription medication coverage not offered through Original Medicare. Medicare beneficiaries who buy into a Medicare Advantage plan must still pay their Medicare Part A or Part B premium.
Nationwide, Medicare Advantage enrollment has more than doubled over the past decade. According to the Kaiser Family Foundation approximately 24 million, or 39%, of Medicare beneficiaries are currently enrolled in a Medicare Advantage plan. Medicare Part C enrollment in South Carolina is at 31%, while neighboring states North Carolina and Georgia have enrollment rates of 40% and 42%. At 43%, Florida has the highest rates of Medicare Advantage in the United States, while only 3% of eligible Wyoming seniors have an MA plan.
There are numerous Medicare Advantage plans available to South Carolina seniors. Over 500 Preferred Provider Organizations, Health Maintenance Organizations and Special Needs Plans (SNPs) are offered along with Private Fee-For-Service (PFFS) and Medical Savings Account (MSA) plans. In this guide, you’ll find an overview of the plan types, information on prescription drug coverage for Medicare Part C beneficiaries and links to Medicare counseling services.
In South Carolina seniors have a number of Medicare Advantage providers to choose from. Plan availability varies between counties and is subject to change each year.
Health Maintenance Organizations (HMOs)
Health Maintenance Organizations, better known as HMOs, provide Medicare Advantage plans that are generally priced lower and include fewer options, than other Medicare Plan C options.
HMO plans provide in-network coverage only. This means members can only receive care through participating doctors and service providers; otherwise, members will need to pay out-of-pocket for medical services and supplies.
HMOs also tend to restrict access to specialists by only covering specialist services for members referred by their primary care physician.
Preferred Provider Organizations (PPOs)
Preferred Provider Organizations, often referred to as simply PPOs, deliver services through a preapproved network in order to control costs. PPO members need to utilize in-network doctors and providers, although members are allowed to access out-of-network care while maintaining some coverage.
PPO members pay the lowest-available co-pays when accessing in-network care; however, unlike HMOs, coverage isn’t automatically denied for care delivered through out-of-network service providers.
Another notable feature of PPOs is that members don’t usually need a primary physician referral to see a specialist.
Special Needs Plans (SNPs)
Geared towards those with specific disabilities or chronic medical conditions, Special Needs Plans cover health services that are designed to meet the needs of seniors with permanent pre-existing health issues. By law, SNPs must include Part D prescription drug coverage.
To qualify for enrollment in a Medicare Advantage SNP, applicants must be either institutionalized, have a severe, chronic disabling condition or be dual-eligible for both Medicare and Medicaid.
Medical Savings Account Plans (MSAs)
Similar to health savings account plans, Medicare MSA plans blend a high-deductible insurance plan with a medical savings account. Under an MSA, the insurance coverage only kicks in once you have paid a high annual deductible, and this deductible varies from plan to plan.
MSA members also have access to a personal medical savings account, or MSA. The plan provider deposits a predetermined amount into this account, and members can use this money to cover health care costs incurred before the deductible is reached each year.
By law, MSA plans must cover the same services provided through all other Medicare Advantage plans. Unlike some other MA options, MSAs often include additional benefits such as vision, dental and long-term care that isn’t covered through Medicare.
Private Fee-for-Service Plans (PFFS)
Medicare PFFS plans are Medicare Advantage plans offered through a private insurance company which provide members with access to prenegotiated service rates that are usually lower than the rack rates.
Some PFFS plans utilize a preauthorized network, while other plans allow members to seek services from any health care provider. Many, but not all, PFFS plans include prescription drug 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.
In South Carolina, seniors with Medicare Advantage can opt for a plan that includes prescription drug coverage, also known as Medicare Part D or Medicare Advantage prescription drug plans. Seniors need to be aware that once they enroll in a Medicare Advantage prescription drug plan, also enrolling in a Medicare Prescription drug plan will automatically terminate their Medicare Advantage plan. By law, all Medicare Advantage special needs plans must include Medicare Part D coverage.
Choosing the best Medicare plan and provider can be tough. Seniors need to carefully consider the costs, coverage options and exclusions before deciding which option best meets their needs. To help make the process easier, we’ve compiled a list of local and statewide resources that assist seniors with Medicare plan selection.
Also called the Insurance Counseling Assistance and Referrals for Elders, or I-CARE program, South Carolina’s State Health Insurance Assistance Program provides free health benefits counseling for Medicare beneficiaries. Families and caregivers of Medicare-eligible seniors can also utilize SHIP services. SHIP is funded solely through federal agencies, and the program is not affiliated with any insurance companies, plans or service providers. Services include assistance with Medicare enrollment for parts A, B, C and D. I-CARE counselors also explain Medicare benefits to seniors, offer Medicaid fraud prevention education and facilitate benefit coordination between various providers. I-CARE counselors also help seniors compare plans during Medicare Open Enrollment and assist clients with applications for cost-saving programs, including the Low Income Subsidy (LIS).
South Carolina’s SHIP/I-CARE program is administered through the statewide network of Area Agencies on Aging. You can find your local Area Agency on Aging by calling the South Carolina Department on Aging at 1-800-434-0222. You can also locate your closest Area Agency on Aging using the search tool on the GetCareSC website.Visit Website
Seniors enrolled in South Carolina’s Healthy Connections Prime program, an enhanced health care plan that combines benefits of Medicare and Healthy Connections Medicaid, can contact the Healthy Connections Prime Ombudsman for help with Medicare. Because the coordination of benefits between Medicaid and Medicare can be somewhat confusing and fragmented, some Prime members struggle with inconsistent care and overuse of emergency room services. The Ombudsman’s office assists Prime members with appeals and grievances, Medicare eligibility and continuity of care issues. The Ombudsman also provides ongoing member education, particularly with regard to member rights and the benefits Healthy Connections Prime members are entitled to. Successful resolutions achieved through the Healthy Connections Prime Ombudsman’s office include prevention of inappropriate discharge from inpatient facilities, assisted members with the Medicaid recertification process and settlement of overdue claims.
South Carolina seniors age 60 and older can access no-cost legal assistance through Area Agencies on Aging Statewide. Funding for these services is provided through the South Carolina Department on Aging, in accordance with Title III-B of the Older Americans Act. The Department on Aging has long-standing partnerships with various legal groups and agencies that provide legal advocacy for seniors, including assistance with Medicare and health care services. Seniors can connect with state-sponsored legal services in their region by contacting the local Area Agency on Aging or by calling the South Carolina Department on Aging at 1-800-868-9095.
The Department on Aging has long-standing partnerships with various legal groups and agencies that provide legal advocacy for seniors, including assistance with Medicare and health care services. Seniors can connect with state-sponsored legal services in their region by contacting the local Area Agency on Aging or by calling the South Carolina Department on Aging at 1-800-868-9095.Visit Website
Serving Berkeley, Charleston, Dorchester, Orangeburg and Williamsburg counties, AccessAbility is a federally funded nonprofit organization that works to empower people with disabilities. Free services include information and referrals and access to medical equipment through two programs: the Equipment Loan Program and the Fee for Service Program. Seniors who have experienced changes to their mobility can borrow durable medical devices through the Equipment Loan Program. The service can help seniors who are evaluating their future medical needs decide if they need a Medicare Advantage plan that includes coverage for mobility aids and accessibility accommodations.
Based in Greenville, Senior Action is a nonprofit organization that provides a variety of services throughout the City of Greenville, Greenville County and the City of Greer. The organization operates a number of activity centers where seniors can participate in wellness, social and recreational classes. Senior Action also hosts a number of financial planning programs and workshops that can help seniors decide if Medicare Advantage enrollment is right for their particular financial situation. Senior action offers free tax preparation assistance, insurance seminars, budgeting seminars and one-on-one insurance counseling and multiple locations.