Medicare Advantage, also known as Medicare C, is the privately offered insurance alternative to Original Medicare Parts A and B. Whereas Original Medicare is a federal program with standardized care, Medicare Advantage is provided by private companies and frequently includes additional coverage that isn’t available with Original Medicare. That added coverage can include hearing, vision and prescription drug coverage, as well as other benefits.
Medicare Advantage originated as the Medicare+Choice program in the late 1990s. It now serves 34% of Medicare recipients across the U.S., although enrollment rates vary between states. Utahns have contributed considerably to Medicare Advantage’s rising profile, with 35% of Medicare recipients in the state choosing Part C alternative to Original Medicare. Compared with neighboring states, Utah is on par with Nevada’s rate of adoption, and slightly above Idaho’s rate of 31%. Colorado and Arizona both have a slightly higher share of Medicare Advantage participants at 38%. Wyoming, on the other hand, has one of the country’s lowest rates of Medicare Advantage enrollment at only 3%.
A variety of plans are available to seniors in Utah looking to enroll in Medicare Advantage. These include Health Management Organization (HMO) and Preferred Partner Organization (PPO) plans, Special Needs Plans (SNPs) and Private Fee-For-Service (PFFS) plans. There are also Medicare Advantage prescription drug plans (MA-PDs) which include prescription coverage. We examine each of these plan types in this guide, along with details about enrollment and resources for seniors seeking assistance navigating all the possible choices to find the right fit for their coverage needs.
Medicare Advantage offers several basic types of plans to beneficiaries in Utah. These include Health Management Organizations (HMOs), Preferred Partner Organizations (PPOs), Special Needs Plans (SNPs) and Private Fee-For-Service (PFFS) options.
Health Maintenance Organizations (HMOs)
Health Maintenance Organizations provide managed care and are also known as HMOs. They generally offer lower premiums than other Medicare Advantage plans, but this comes at the cost of limitations on participants’ care choices. The doctors and other providers that an HMO plan member has access to are limited to a specific care network. Going to an out-of-network provider can leave a member responsible for their full cost of care. HMO plans also tend to require a referral from a member’s chosen in-network primary care physician to access specialist services.
Preferred Partner Organizations (PPOs)
The Preferred Partner Organization (PPO) plan is similar to its managed care HMO counterpart, but with important differences. Like HMOs, PPOs require beneficiaries to seek care from within a specific provider network if they want to pay the lowest costs for services. In contrast to HMOs, PPOs allow their participants to go out of network to receive services, while still receiving at least partial coverage. PPO members also generally don’t require a referral from a primary care physician to access specialist care. This relative flexibility typically comes with the trade-off of higher premiums.
Special Needs Plans (SNPs)
Enrollment in Special Needs Plans, or SNPs, is limited to a specific population, such as residents of nursing homes or other institutional care settings, the disabled and those suffering from certain chronic illnesses or individuals who have dual Medicare and Medicaid eligibility. Each SNP coordinates a network of service providers and health care facilities to offer care tailored to meet the needs of the population it serves. Enrollment in an SNP is limited to Medicare beneficiaries who match the population profile the plan serves. By law, all SNPs are required to provide prescription drug coverage.
Private Fee-For-Service (PFFS)
Private Fee-For-Service (PFFS) plans contract with providers on a case-by-case basis to provide services to the plan’s participants at agreed-upon rates. PFFS plans offer members the greatest freedom of choice in terms of providers. Instead of limiting members to receiving care from a network of providers, enrollees can seek services from any doctor, clinic or hospital that agrees to the plan’s terms of payment. This typically comes at the cost of higher monthly premiums compared to HMO and PPO plans. PFFS plans may also offer prescription drug benefits for a separate monthly premium.
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.
Prescription drug coverage under Medicare is referred to as Medicare Part D. There are two possible ways to get prescription drug coverage in Utah, which isn’t covered under Original Medicare. One is to get a stand-alone Medicare Part D plan; however, Utah residents who enroll in Medicare Advantage are prohibited from enrolling in a stand-alone Medicare Part D plan at the same time. These individuals can opt to enroll in Medicare Advantage plans that also include prescription drug coverage, which are commonly referred to as MA-PD plans. MA-PDs in Utah may often have monthly premiums as low as $0, although participants are required to continue paying their Medicare B premiums.
Medicare Advantage offers a valuable health care resource for Utah seniors. However, it can be a challenge for individuals to sift through all the information and possible alternatives to find the plan that’s best for them. Below, we provide a guide to state and local resources that can help seniors find the right Medicare Advantage coverage for their needs and successfully navigate the application process.
The State Health Insurance Information Program (SHIIP) is a nationwide program operating in many states, including Utah. It provides free and impartial one-on-one counseling and assistance to adults 60 or older who are eligible for Medicare, both via telephone and in face-to-face sessions, to help people find the right Medicare and Medicare Advantage plans. It also puts on public Medicare education programs and courses for people of all ages.
Take Care Utah is an initiative of the Utah Health Policy Project (UHPP), specifically designed to guide people to accurate information about enrollment and coverage in health care plans, with navigating with the health care marketplace and understanding of their options, including plans offered through Medicare and Medicare Advantage. Take Care Utah guides individuals to counseling and information resources, and provides free assistance with applications and enrollment.
Utah’s ADRC and C2C initiatives are a collaboration between the Centers for Medicare and Medicaid Services, the Veterans Health Administration and the U.S. Administration on Community Living. Together, they’re designed to allow seamless access to long-term services and supports for older adults and people with disabilities, creating a “one-stop shop” for anything these individuals may need. The COVER to COVER program is sponsored by the Office of Rural Health and Geriatrics and Extended Care and designed to support access to benefits and programs for rural veterans within their communities, in collaboration with Area Agencies on Aging and other community partners.
The Utah Department of Health provides a number of services through its Office of Health Care Statistics that can be helpful with Medicare enrollment and navigation, such as public access to data comparing Utah health plans and hospital costs, answers to common questions about health care in the state and guidelines to using and interpreting the data on their site. Many of the reports compiled from this data are freely accessible by the public and can be an invaluable resource in evaluating Medicare and Medicare Advantage options.
The mission of the Utah Insurance Department is to make sure that insurance products offered in the state are affordable, reliable and accessible to all on fair terms. It serves and protects consumers residing in the state of Utah through insurance law and regulation, following up on insurance complaints, licensing and certification of cross-border insurers and other initiatives. It also provides general information and counseling about health insurance, including Medicare Advantage plans.
An initiative of the United Way of Utah, 2-1-1 Utah is a comprehensive information portal to find a wide range of services in the state, including health insurance counseling. The service can be accessed by phone or via a smartphone app. The 2-1-1 Utah resource is directly tied to Take Care Utah, which is similarly dedicated to helping people navigate health insurance options.
A group of community health centers that takes a holistic approach to health and wellness, the Bear Lake Community Health Center has Utah locations in Garden City, Providence, North Logan and Brigham City, as well as several sites out of state. In addition to providing access to quality primary and urgent medical care regardless of ability to pay, the center provides information services that help seniors with navigating health care coverage options, including Medicare and Medicaid, and finding economically efficient choices.
BLCHC’s administration offices can be reached by phone at 435-755-6061, or by mail at 517 West 100 North, Suite 210, Providence, Utah 84332. A directory of their clinic locations and contact information can be found on their website.Visit Website
Based in the College of Social Work in Salt Lake City’s University of Utah, the Goodwill Neighbors Helping Neighbors program is over two decades old. Its focus is on providing services for seniors and collaborating with community partners in helping older adults adjust to the challenges of aging. NHN mobilizes students to support seniors in learning about preventative health measures, rehabilitative and support services and how to navigate issues with medical insurance coverage. The program provides information and referral support, individual and family counseling and help with applications for a range of public services. These services come with no financial eligibility requirements and are prioritized for those most in need of help.
The NHN program can be contacted by phone at 801-585-9505 or 801-585-9156. More information about the program can be found on its website.