Basic Medicare (Parts A and B of the federal Medicare program) is unfortunately plagued by gaps in coverage which, if left unaddressed, could costs you thousands in hospital bills down the road. One solution for protecting seniors from such expenses is to purchase a Medicare Advantage (Medicare Part C) policy. It is a comprehensive, private health insurance plan which replaces your federal Medicare benefits with similar coverage.
Federal Regulations for Medicare Advantage
For the protection of seniors, federal laws regulate Medicare Advantage to make sure that you get equal to or better coverage than Parts A & B of Medicare. Most policies offer the basic Medicare benefits, as well as special coverage designed to protect you from costly Medicare gaps. Furthermore, you can bundle optional coverages to your policy, including Medicare Part D prescription drug benefits.
Medicare Advantage Enrollment In Connecticut
Medicare Advantage plans have a fairly strong presence in Connecticut, all things considered. Nearly a quarter of qualified seniors (28%) have signed up for one of these policies in order to protect themselves from gaps in Medicare coverage. Below, you can see how Medicare Advantage plans break down, and who typically signs up for them:
|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
Like any other type of insurance, there are dozens of factors which will alter your monthly rates. Your exact location will have a major influence, as well as health status, gender, and how much you can afford to spend on your policy. Below are some estimated rates for seniors in your area:
Most Popular Medicare Advantage Plans in Connecticut
Medicare established the Overall Star Rating system as a way for consumers to see a third party evaluation of every company that offers Medicare services or products. Medicare gathers information and surveys users of every company participating in this market. For companies like Medicare Advantage providers, Medicare rates them on use of preventive medicine strategies like inoculations and screenings, management of chronic diseases, membership experiences and changes in performance, and the customer service function. The more Stars the better. You can use this annual report to help evaluate a company you are interested in.
Helpful Medicare Advantage Tips & Tricks
Doctor/Provider Network Restrictions
If you don’t have a preferred doctor or hospital where you get your medical care, then network restrictions may not be a factor for you. But for many seniors, signing up for a Medicare Advantage policy could force them to start receiving medical care elsewhere. PPOs and PFFS networks are great if you need the flexibility of choice; however, restrictive HMOs will make your plan more affordable.
Where you generally need to get your care and services from for:
- HMO Plans: If you join a Medicare Advantage plan that is an HMO, you won’t have much in the way of choices when it comes to providers. HMOs operate comprehensive networks staffed with primary physicians, specialists, hospitals, labs, etc. You may or may not be able to choose your primary doctor but once you see him or her, it is his or her responsibility to direct you to other physicians and facilities in the network.
- PPO Plans: Preferred Physician Organizations (PPO) have networks like HMOs. The difference is you are free to select your own providers, the PPO will not assign them. In addition, you can select healthcare providers that are outside the network providing they accept the plan’s coverage. Using providers that are in-network is significantly less expensive in terms of copay than using out-of-network providers and facilities.
- PFFS Plans: You are free to choose any healthcare provider you want with a Private Fee For Service plan. The catch is those providers have to accept your plan and many won’t even though they accept Medicare patients. PFFS plans tend to pay providers less than other types of plans. Consequently, many providers and facilities will not enter into agreements with them. Before you see a healthcare provider, make certain they will accept your insurance.
- Special Needs Plans: If you have a chronic condition or illness, live in a nursing home, or qualify for both Medicare and Medicaid, you are probably in a Special Needs Plan and your healthcare providers will be limited to the specialists in the Medicare SNP Network. These are highly focused groups with all providers and facilities specializing in your specific condition.
Finding a doctor who accepts your Medicare Advantage plan:
- HMO Plans: With an HMO Medicare Advantage plan you won’t have to worry about finding a healthcare provider that accepts your plan. That’s because the only providers you can use are those in the HMOs network. You might be able to select your own HMO member primary physician, but if you need additional services, your primary will select them and direct you to them.
- PPO Plans: Often PPO Medicare Advantage plans will have online directories listing all their providers. Many give short bios and some have patient ratings and reviews. Like all directories, the information is subject to be dated. When you call to make your first appointment, confirm that the doctor accepts your plan.
- PFFS Plans: PFFS have no restrictions on which healthcare providers use. You can use your existing doctor(s) if you like, but only if they accept your PFFS plan. Many won’t. Some PFFS plans have directories of providers that will take the coverage, but it is a good practice to confirm acceptance when making an appointment.
- Special Needs Plans: Like an HMO, if you are in a Special Needs Plan, your providers have already been chosen for you. They are the specialists of the Medicare SNP Network. These physicians and facilities specialize in your specific medical situation.
The Medicare’s physician search tool makes finding doctors who accept Medicare easy. Medicare Advantage plan companies all have similar online tools so finding providers is easier than you might think.
Drug, Vision and Dental Coverage
The biggest benefit of a Medicare Advantage policy, despite its drawbacks, is the convenience of bundling your coverage together under one policy. Dental, vision, prescription drugs, and your basic Medicare benefits are all covered under a single policy through a single entity. For some seniors, however, this means paying a premium price for that convenience.
- Limited eye care is a benefit not provided by Medicare but often is provided by Medicare Advantage plans. Typically, this benefit is limited to an annual eye exam and lenses, glasses, and contacts. Check your plan’s directory to find participating optical shops. Many offer discounts for plan members for frames and other devices.
- Dental care is not a benefit that Original Medicare provides. However, many Medicare Advantage plans offer their members limited dental services. Participating dentists provide a routine annual exam including x-rays, cleanings, and filings. Additional dental care like veneers, crowns, and dentures, are normally not covered by the plan.
Enrollment Options & Best Time To Enroll
Because you are applying for health insurance coverage from a private company, they are more likely to screen you for health problems before offering you a policy, or reject you for having serious pre-existing conditions if you fail to enroll during Open Enrollment. Complicated ailments, such as End Stage Renal Disease, will make it more complicated (but not impossible) to get covered. Your state department of insurance will have information and resources for any senior who is having trouble obtaining coverage due to ESRD or any other serious illness. For more information on enrollment, consult our Medicare Advantage Enrollment Page.
- Initial Enrollment Period: For best results, try to enroll in a Medicare Advantage plan within your first 6 months of Medicare enrollment.
- Annual Enrollment Period (AEP): You have the option of changing or cancelling your Medicare Advantage and Part D drug plan between October 15th and December 7th every year.
- Special Enrollment Period (SEP): If you lose your employer plan coverage, move out of your coverage area, or lose coverage from your provider, you could qualify for an SEP.
What Medicare Advantage Plan Is Best For Me?
Only you can decide what makes a perfect Medicare Advantage plan for your specific needs. We would recommend that it should be one you fully understand, offers physicians and facilities that meet your needs and you have confidence in, and that fits your healthcare budget. It’s out there. You just have to do the research to find it and we hope we can help you with that.
Premiums are always an important consideration, but many Medicare Advantage plans have zero-premium offers. If you are considering one of these, check the copays and deductibles for both in and out-of-network providers to determine your out-of-pocket expenses. Also take into consideration the company’s reputation, amount of time serving your area, and financial stability. Do the research and you’ll find the perfect plan. And make sure you enroll within your determined enrollment period so that you don’t miss out on your opportunity to save on medical costs.