Medicare Advantage plans provide seniors and other Tennessee residents with affordable and comprehensive health insurance. Also known as Medicare Part C, these plans include the same coverage as Original Medicare Parts A and B, and often include additional coverage for health care services that aren’t covered by Original Medicare, such as vision and dental care. Some Medicare Part C plans also include prescription drug coverage.
Private insurance companies throughout Tennessee administer Medicare Advantage Plans. These companies collect premiums from plan participants and are paid by Medicare for services that fall under Medicare Parts A and B. Seniors who receive Social Security benefits may have part of their premiums deducted from their benefit payments.
According to the Kaiser Family Foundation, 39% of U.S. Medicare beneficiaries are participating in a Medicare Advantage plan. In Tennessee, this enrollment rate is even higher at 42%. In surrounding states, enrollment rates are fairly similar. While Kentucky’s rate is slightly lower at 37%, the enrollment rate in Alabama is a little higher at 45%.
In Tennessee, there are several options when it comes to Medicare Advantage plans. Seniors in the state can choose from HMOs, PFFSs, PPOs and SNPs. Additionally, while some of these plans may include limited prescription drug coverage, seniors may want to include Medicare Part D in their Medicare Advantage plan, which exclusively covers the cost of prescription medications. In the information that follows, we’ve included information about each of the Medicare Advantage plans that are available in Tennessee, as well as several resources in the state that can help seniors navigate the ins and outs of these complicated policies.
In Tennessee, there are several types of Medicare Advantage plans available to seniors. These include Health Maintenance Organizations (HMOs), Private Fee-For-Service plans (PFFS), Preferred Provider Organizations (PPOs) and Special Needs Plans (SNPs). Plans may vary in terms, price and coverage inclusions depending on the provider. Additionally, all plans from all providers may not be available throughout the state.
Health Maintenance Organizations (HMOs)
HMOs generally cost less than other types of Medicare Advantage plans, but they’re also far more restrictive. When participating in an HMO plan, seniors are required to elect a primary care physician from within their insurance company’s network. This physician is responsible for overseeing all patient care and must provide referrals in the event that a specialist is required. Treatment must be provided by in-network or referred practitioners. Patients who seek care outside of this network may be responsible for paying the full cost out of pocket.
Private Fee-for-Service Plans (PFFS)
PFFS plans offer the most flexibility compared to other Medicare Advantage plans. When enrolled in a PFFS, patients may seek care from any health care practitioner they wish. Their insurance company will pay a predetermined fee for the service or treatment provided, leaving the patient to pay any remaining charge. The fee for each service varies depending on the insurance provider. It’s important for enrollees to ensure the health care practitioner they receive care from will accept their coverage, as some providers may not accept PFFS plans.
Preferred Provider Organizations (PPOs)
Just as with an HMO, PPOs have specific provider networks that insurance companies prefer to work with. However, these plans combine this policy with the flexibility of PFFPs, allowing patients to seek care from any health care provider they wish. By seeking care within the network, plan participants pay lower co-pays. If a plan member wishes to receive care from an outside provider, their coverage amounts are reduced and they will have a higher co-pay amount. The monthly premiums charged by PPOs are usually higher than those of HMOs.
Special Needs Plans (SNPs)
SNPs are designed to meet the health care needs of certain groups of people, such as those who are eligible for both Medicare and Medicaid or have chronic diseases or illnesses like end-stage renal failure, cancer or autoimmune disorders. These plans tailor the services they cover and the providers they work with to deliver care targeted to their group’s condition or situation. SNPs are required to include prescription drug coverage, and enrollment is restricted to individuals who qualify to be part of the group the plan serves.
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.
Depending on the plan and the insurance provider, some Medicare Advantage plans may cover the cost of prescription medications. When shopping for a plan, it’s important that seniors understand whether or not this coverage is included. In some cases, those who don’t have prescription drug coverage may want to enroll in Medicare Part D, which covers the cost of prescription medications. Medicare Part D premiums vary depending on the provider and the level of coverage obtained.
In Tennessee, Part D can be combined with Medicare Advantage in cases where the beneficiary’s plan does not include drug coverage. However, most Medicare Advantage plans that do include drug coverage cannot be combined with Part D. Beneficiaries who have a Medicare Advantage plan with prescription drug benefits risk being disenrolled from their MA plan if they obtain Medicare Part D benefits, as well.
Medicare Advantage plans can be confusing for many enrollees. There is often a plethora of different providers available, each offering different plans at different prices. For many seniors, it can be helpful to have someone who understands the ins and outs of Medicare to provide assistance in choosing a plan. Below, we’ve listed several state and local resources throughout Tennessee that offer such assistance, as well as help with insurance claims, appeals and complaints.
TennCare is Tennessee’s state Medicaid plan. While it doesn’t administer Medicare plans, it does provide some assistance to individuals who require assistance determining their eligibility for Medicaid or Medicare programs. Additionally, it offers benefits coordination assistance to beneficiaries who are dually eligible for Medicaid and Medicare.
Seniors can contact TennCare by calling (855) 259-0701.
The Tennessee Department of Commerce & Insurance regulates all health insurance providers throughout the state, including those that provide Medicare Advantage plans. Seniors can contact this department if they wish to verify an insurance agent or file a complaint about their provider. This department also offers consumer education resources about Medicare Advantage and other insurance policies.
Seniors who wish to contact the Tennessee Department of Commerce & Insurance can call (615) 741-2241.
State Health Insurance Assistance Programs (SHIP) are federally-funded programs that are available in every state. In Tennessee, the SHIP program offers regular educational and counseling events in various cities throughout the state for Medicare beneficiaries and potential enrollees. These events help seniors to access the information they need to choose appropriate Medicare or Medicare Advantage plans to suit their needs.
Seniors who are U.S. veterans, as well as their immediate family members and dependants, can access health insurance counseling from the Tennessee Department of Veterans Services. This department administers its own benefits but can also provide coordination and other assistance services to those who carry Medicare Advantage policies.
The Aging and Disability Resource Center (ADRC) offers a variety of services and supports for seniors and their caregivers. Its staff are qualified to provide insurance counseling services to Medicare Advantage beneficiaries. Other services that seniors can access at ADRC locations include transportation services, nutritional counseling and caregiver training.
Seniors can contact Tennessee’s ADRC by calling (866) 836-6678.
This Area Agency on Aging office serves seniors in 13 counties in the Nashville area and throughout Southeast Tennessee. The office provides information and assistance to seniors in a variety of matters. Its services include insurance counseling for Medicare participants.
The Greater Nashville Regional Council (GNRC) offers Medicare counseling services for senior citizens as part of the federal SHIP program. The services provided by this program are free of charge and this organization is not affiliated with any insurance providers; therefore, information provided to beneficiaries is entirely non-biased.
Seniors can visit the Greater Nashville Regional Council at 220 Athens Way, Suite 200 in Nashville or call (615) 862-8828 for more information.
Serving seniors in Shelby County, the Aging Commission of the Mid-South helps seniors with a variety of free and low-cost supports and services. This Area Agency on Aging and Disability employs SHIP-certified insurance counselors who provide seniors with Medicare counseling, as well as assistance with Medicare Advantage claims, appeals and complaints.
The Aging Commission of the Mid-South is located in the Vasco A. Smith, Jr. County Administration Building at 160 North Main St. in Memphis. For more information about the programs and support services this office offers, seniors can call (901) 222-2300.