Medicare Advantage, also known as Medicare Part C, is a private insurance alternative to Original Medicare Parts A and B. Instead of receiving Medicare benefits from the government, Part C users purchase plans from private insurance companies, much like standard private insurance offered through an employer or the health care marketplace. Unlike Original Medicare, which is highly standardized, Medicare Advantage plans are available in a variety of forms that can contain additional coverage options. These plans can also include prescription drug coverage, which is not a feature of standard Medicare.
Some states use Medicare Advantage plans more than others. Nationally, 34% of Medicare users choose to purchase a Part C plan, according to the Kaiser Family Foundation. Vermont’s usage is far below the national average and tied with Maryland for the second-lowest use nationwide at 11%; Alaska is last at 1%. This penetration rate for Medicare Advantage is far below neighboring states. New York has a usage rate of 39%, while New Hampshire sits at 17% and Massachusetts at 22%. Maine is higher as well, with 33% of residents choosing Medicare Advantage.
Medicare Advantage plans vary and are available from numerous providers in Vermont. Plans come in several distinct types as well, including HMOs, PFFSs, PPOs and SNPs. This guide summarizes what Vermont residents need to know about Medicare Advantage plans, including the differences between each type of plan. In addition, seniors who need help making the right choice or comparing plan options can contact the trusted resources listed below.
Medicare Advantage plans come in several different types in Vermont, including Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-For-Service Plans (PFFS) and Special Needs Plans (SNP). Each of these plan options has pros and cons seniors should consider when making a decision.
Health Maintenance Organizations (HMO)
HMO plans are among the most common forms of Medicare Advantage plans. This plan type relies heavily on a network of providers; care must be provided by approved doctors and facilities to qualify for benefits. Out-of-network care is often not covered at all. HMO members who need to see a specialist must get a referral from a primary care provider. HMOs are often one of the most affordable forms of health plans, with lower premiums in exchange for more limited access to health care. HMO plans can include prescription drug coverage, but it’s not required.
Private Fee-For-Service Plans (PFFS)
PFFS plans are, as the name implies, a form of plan in which reimbursement is based on a stated fee per service. In this form of plan, the amount an insurance company pays for a stated procedure or treatment is predetermined. Unlike HMO and PPO plans that rely on some sort of network, many PFFSs subscribers can use any provider who takes Medicare. These plans can be more affordable than other alternatives, but plan members need to contact hospitals and providers in advance of care to determine both eligibility and cost expectations. Some PFFS plans may include prescription drug coverage, but this is not mandated under Medicare policies.
Preferred Provider Organizations (PPO)
PPOs are among the most popular choices for Medicare Advantage members. These plans are more expensive but usually provide more flexibility and expanded reimbursements than other alternatives. While the use of a network still applies, procedures and services from out-of-network are often still covered in part. Further, subscribers don’t need a referral to see specialists. Some PPO plans do offer prescription drug coverage, but this isn’t required.
Special Needs Plans (SNP)
SNP plans are the least common form of Medicare plan but can be a valuable tool for those in need. These plans provide specialized coverage for those with a specific form of chronic illness or disability, making it easier for people with unique requirements to receive the care they need. SNP plans aren’t available to everyone; instead, enrollment is limited to only those with qualifying conditions. Unlike all other forms of Medicare Advantage plans, SNPs must offer 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.
Prescription drug coverage can be an important consideration for seniors, especially for those who have significant medication requirements. Medicare Advantage plans can include this kind of coverage, but PFFS, PPO and HMO plans aren’t required to offer it. Seniors who want prescription drug coverage in Vermont must choose a plan that does provide this coverage because there’s no way to combine traditional Medicare Part D with Medicare Advantage plans. Enrolling in Medicare Part D results in an automatic disenrollment from Medicare Part C. Seniors with prescription drug coverage through an employer or union are not encouraged to move forward with Medicare Advantage. Some plans have prescription drug coverage included in premiums, while others require an additional cost per month.
It’s not unusual for seniors in Vermont to have trouble finding the right Medicare plan. This includes comparing Medicare Advantage and Original Medicare plans. These statewide and local resources can help seniors compare their options and make the right Medicare choices for their own unique health care needs.
Vermont’s State Health Insurance Program is a free counseling service available to provide information, support and assistance to eligible seniors seeking Medicare coverage. Seniors can call with questions and concerns about choosing a Medicare plan and receive confidential and unbiased information and resources. Counseling extends to both private and public insurance options, as well as supplemental policies and long-term care insurance. SHIP can also help those using Medicaid or VPharm to coordinate coverage. This service is organized through Vermont’s Area Agencies on Aging and is available to all seniors eligible for Medicare, as well as their family members and caregivers.
Vermont Health Connect is Vermont’s health insurance marketplace, serving all qualified individuals as well as seniors in need of Medicare or Medicaid support. Seniors can browse their options using the plan comparison tools or call to find out about plans and benefits. Vermont Health Connect’s services are free to use and are available on a daily basis to answer insurance questions and help Vermont residents enroll in insurance plans. Those who want who meet with someone from VHC in person can do so in locations situated regionally throughout the state.
Vermont Legal Aid is a nonprofit organization that provides fair and unbiased legal support for low-income citizens of the state of Vermont. In addition to more standard civil legal services, Vermont Legal Aid also offers Medicare support, including a comprehensive FAQ page on its website and access to a help line. Seniors with questions about Medicare, those who would like to connect to additional Medicare resources or those who have other general legal questions about Medicare coverage can call to receive custom support from a legal perspective.
Green Mountain Care is a division of Health Access Member Services of the Department of Vermont Health Access. Its focus is on connecting low-income individuals with cost-saving opportunities. For seniors on Medicare who are having trouble affording benefits or who need other forms of financial assistance, Green Mountain Care can provide information about options such as Medicaid and prescription drug cost aid. In addition, the organization can connect seniors with other financial assistance programs, such as meal assistance, live-in caregiver resources and access to basic health screening to make getting health care with Medicare more affordable. Green Mountain Care is available to anyone who qualifies for Medicaid, including seniors on Medicare looking for additional resources.
The Central Vermont Council on Aging is one of Vermont’s Area Agencies on Aging serving the Central Vermont region, including the capital of Montpelier. For people living in this area, numerous Medicare counseling resources are available. In addition to offering support through the State Health Insurance Program, CVOCA also hosts in-person Medicare & You information sessions on a regular basis at locations throughout Central Vermont. Currently, sessions are also being held over the Zoom video call platform, allowing seniors from all over the state to participate. In addition, CVOCA offers Part D prescription drug counseling services from October to December each year. The Central Vermont Council on Aging is available for all seniors living in the Central Vermont region as well as those living throughout the state for virtual information sessions.
An invaluable resource for seniors in Southeastern Vermont, including Windham and Windsor counties, Senior Solutions is one of Vermont’s Area Agencies on Aging. Offering extensive options for seniors, Senior Solution’s main benefit is its comprehensive help line service. Using a thorough Medicare planning option, the representatives at Senior Solutions can offer free and unbiased counseling services to empower seniors making Medicare decisions. Counseling includes private and public plan options, like Medicare Advantage and Original Medicare. Senior Solutions can also connect seniors with other necessary resources, including Medicaid, day programs, home health resources, transportation options, Meals on Wheels, prescription assistance programs and Social Security. Senior Solutions is available to all seniors living in the Southern Vermont area.