Original Medicare (Medicare Parts A and B) possess some unfortunate coverage gaps which, if left uncovered, could become expensive in the future. If you want to protect yourself from these future charges, Medicare Part C (a.k.a. Medicare Advantage) could be a potential solution for you. Medicare Advantage policies are issued by private insurance companies which offer the same coverage as Original Medicare, and usually some additional benefits which help protect you from expensive gaps. However, the government will no longer be responsible for your Original Medicare coverage.
Federal Regulations for Medicare Advantage
Federal consumer protection laws prevent any provider of a Medicare Advantage policy from selling you coverage which is less comprehensive than Traditional Medicare. Your Medicare Advantage benefits, therefore, will be as good, or better, than Medicare Parts A and B. They will also likely include protection from Medicare coverage gaps, prescription drugs benefits (a.k.a. MAPD plans), and other extras.
Medicare Advantage Enrollment In Arizona
There are many seniors 65+ in Arizona who are currently receiving some sort of Medicare benefits, whether it’s Traditional Medicare alone or Medicare with a supplement. Of those, 39% have chosen to sign up for a Medicare Advantage policy. But not all of these policies are exactly alike. Consult the chart below for a breakdown of plans, as well as the percentage of enrollees each one has.
|Plan Type||Enrollment Percentage|
|Local PPO Plans||13%|
|Special Needs Plans||11%|
|Regional PPO Plans||9%|
|Private Fee-For-Service Plans||5%|
|Other (Cost Plans, MSA’s, etc.)||3%|
Plan Coverage & Cost
The fact that you live in Arizona, as opposed to somewhere like Pennsylvania, will have a significant influence on your rate with a Medicare Advantage plan. Age, Medicare enrollment status, and other factors will also change how much you can expect to pay. Reference the chart below for estimated plan rates near you:
Most Popular Medicare Advantage Plans in Arizona
Medicare reviews the data it has collected on all companies providing Medicare related products and services and issues an Overall Star Rating report annually. For companies that provide healthcare services, Medicare evaluates how well each company performs in the areas of preventive medicine like screenings and vaccinations, managing chronic diseases, member experiences with the company and changes in company performance, and customer service. These ratings can be useful in evaluating a plan that you are interested in.
Helpful Medicare Advantage Tips & Tricks[IMPORTANT INFORMATION & FACTS IN GLOBAL CONTENT]–>
Doctor/Provider Network Restrictions
One of the most complicated aspects of Medicare Advantage plans are the network restrictions. For the most part, you are only permitted to get medical care from the pre-approved doctors and facilities which your plan has chosen. Some of these plans offer more choice than others, so do your research into which plans offer what access in your area. Also, keep in mind that rules and restrictions can change at any time, and may hinder your ability to get care in the future.
Where you generally need to get your care and services from for:
- HMO Plans: If your Medicare Advantage plan is set up as a Health Maintenance Organization (HMO) your choice of healthcare providers including primary doctor, specialists, hospitals, labs, etc. will be restricted to those that are part of the HMO’s network. Emergencies are the exception to that rule. Emergency care or urgent care or out-of-state dialysis are all covered under the HMO model. Some will also have an option for you to select an out of network provider (Point of Service) but your cost for that service will be significantly higher than using network providers.
- PPO Plans: Some Medicare Advantage plans are modeled as Preferred Provider Organizations (PPO). These plans will allow you to use any healthcare provider who will accept the coverage but your cost (copay) is much lower if you use providers who are on the PPO list or network. Most plans with this model have online lists of preferred providers that you can check before making your buying decision.
- PFFS Plans: Private Fee For Services (PFFS) plans have no restrictions on which healthcare providers you select so long as they accept the plan. Not all will even if they accept original Medicare. PFFS plans normally have a list of providers who will accept the plan available to members. However, it’s important you confirm the plan is accepted when you make an appointment, even if you have used the provider before, to ensure you still have coverage.
- Special Needs Plans: If you qualify for a Special Needs Plan you will typically be restricted to healthcare providers and facilities that are part of the Medicare SNP Network. Exceptions to these limitations include services received for emergency or urgent care required by a sudden onset of illness or injury, and End Stage Renal Disease dialysis outside the area
Finding a doctor who accepts your Medicare Advantage plan:
- HMO Plans: If you are considering a HMO plan, you really only have to find a primary physician you’re happy with. With an HMO, all health services including specialists, hospitals, labs, in-home care, etc. are provided by the HMO’s network. Your primary care doctor is tasked with referring you to those resources. You don’t have to search them out.
- PPO Plans: PPOs also have networks of “preferred providers” practicing all forms of healthcare services. However, unlike HMOs, PPOs allow you to choose any provider in or out of the network. If you choose an out-of-network provider, you will typically pay significantly more as a copay.
- PFFS Plans: Private-Fee-For-Services (PFFS) plans have no restrictions on which healthcare provider or facility you use so long as the provider accepts the plan’s payment schedule. Not all providers will. In fact, it is a good practice to ensure that the provider accepts your plan when making an appointment. This is a practice you should follow even if the provider has accepted your coverage in the past.
- Special Needs Plans: If you have a chronic disease, live in a nursing home, or qualify for both Medicare and Medicaid, you may qualify for a Special Needs Plan or SNP. If you are in one of these groups, your selection of providers will be limited to Medicare’s SNP Network. These networks are comprehensively staffed with specialists and facilities focused on your specific condition.
Finding a doctor that you trust and is qualified to treat your specific medical needs is a primary concern when selecting a Medicare Advantage plan. Most plans will have an online directory of available healthcare providers very similar to Medicare’s physician search tool. You can check that list to see if your personal provider is a member and what hospitals and specialists are available. Just keep in mind that there are some conditions in physician availability.
Drug, Vision and Dental Coverage
One advantage which Medicare Part C plans have over the competition is the convenience of bundling different coverage benefits into one policy. Medicare Advantage is one of the few supplements which can provide you with Vision, dental, and Medicare Part D prescription drug coverage all within the same policy. However, you will pay a higher rate for this convenience.
- Original Medicare has eye care benefits limited to exams for diabetic retinopathy and age related macular degeneration. Many Medicare Advantage plans offer additional eye care coverages like an annual eye exam, lenses, glasses, and contacts. These services are typically limited to a specific local provider like LensCrafter.
- Another benefit that many Medicare Advantage plans offer that is not available through Original Medicare, is dental care. While the services have to be provided by a participating dentist, services include routine annual dental exams including cleanings, X-rays, and fillings. Check the plans directory to find which dentists near you participate.
Enrollment Options & Best Time To Enroll
As a warning, you should know that applying during the Open Enrollment Period will protect you from medical underwriting, which can sometimes alter the affordability of your plan based on pre-existing conditions outside of this enrollment window. With the exception of ESRD (End Stage Renal Disease), though, most seniors can easily get coverage if they are in good health and new to Medicare. For more information on enrollment, please take a moment to visit our Medicare Advantage Enrollment Options page. And make sure you get in touch with a licensed insurance agent to properly evaluate your circumstances, as well as your options.
- Initial Enrollment Period: 6-month time frame when you first enroll in Medicare to purchase a Medicare Advantage plan.
- Annual Enrollment Period (AEP): This time frame runs from October 15th through December 7th every year, and during this time you can change or cancel your Medicare Advantage and part D drug plan.
- Special Enrollment Period (SEP): During special circumstances, you may be eligible to purchase/change a plan outside of the Annual Enrollment Period. Things such as moving out of the plans’ service area, losing group health or employer coverage, a company no longer offering plans in the area, etc. are all events that could trigger a SEP.
What Medicare Advantage Plan Is Best For Me?
The best Medicare Advantage plan for you is one that you fully understand, offers the providers and facilities that you trust, and has deductibles and co-pays that you can afford. If a plan offers Part D drug coverage, you want to ensure that the pharmacy has your medications. Only you can decide what the plan is for your specific situation but if you stick to the guidelines above, and do your research, then you will find a perfect plan.
Premiums are always a major concern when making a decision and it gets tricky with Medicare Advantage plans. Many have zero-premium plans. If you qualify for one of these plans then pay special attention to copays and deductibles. Also you want to take into consideration the reputation and financial stability of the company. If you can accomplish all of this within your plan’s limited enrollment period window, you’ll be sure to save money on your healthcare costs.