Written By: Roseann Birch; Reviewed by: Leron Moore
October 20, 2020
Medicare Advantage, also called Medicare Part C, is an alternative to Original Medicare. It provides the same coverage as Medicare Parts A and B, and in many cases, it offers additional benefits, such as prescription drug, vision, and dental coverage. While Original Medicare is managed by the federal government and provides standardized benefits to each policyholder, Medicare Advantage is offered by private health insurance companies. Benefits, premiums, and maximum annual out-of-pocket limits vary from one policy to another. Unlike Original Medicare, which is available to seniors aged 65 and older regardless of where they live in the United States, the availability of specific Medicare Advantage plans varies based on location.
Medicare Advantage plans are similar to comprehensive health insurance plans offered by employers and on HealthCare.gov. Depending on where an individual lives, they have several different plans to choose from. Some plans require members to receive healthcare services from in-network providers, while others may be used at any doctor or hospital that agrees to the plan’s payment terms. The plan an individual chooses should be based on their budget and medical needs.
Types of Medicare Advantage Plans
The Illinois Medicare Advantage program includes four main types of plans, HMOs, PPOs, PFFS plans, and SNPs, which each provide unique benefits for policyholders. These plans are offered by several insurance companies and range in eligibility and enrollment requirements. Not all plans are available in all regions of the state. Medicare beneficiaries may wish to speak with an options counselor to determine whether one of these plan types is right for them.
Health Maintenance Organizations (HMO)
An HMO is a network of doctors, hospitals, specialists, and other healthcare providers that contract with the health insurance company to provide services at a negotiated rate. In most cases, seniors enrolled in HMOs must get their care and services from an in-network provider. Some exceptions to this include emergency care, urgent care received when the member is away from home, and out-of-area dialysis. Seniors generally need to choose an in-network primary care doctor when they enroll in an HMO plan, and they usually need to get a referral to see a specialist. Most HMO plans cover prescription drugs. Because Medicare Part D can’t be added to an HMO plan, seniors who want this coverage should ensure that it’s included in the plan they choose.
Preferred Provider Organizations (PPO)
Like HMOs, PPO plans have networks of healthcare providers and often cover benefits not offered under Original Medicare Parts A and B, such as vision, dental, and prescription drug coverage. Members aren’t required to use a provider within their network, although it’s usually cheaper to do so. It isn’t necessary to choose a primary care doctor, and in most cases, referrals aren’t needed to see a specialist, which may cut down on the time it takes to get medical treatment. Medicare Part D prescription drug coverage can’t be added to a PPO plan, so seniors who want this coverage should opt for a plan that includes it.
Private Fee-For-Service Plans (PFFS)
While HMO and PPO plans are comparable to the private health insurance plans that many seniors had before retirement, PFFS plans are specific to Medicare. This type of plan can be used at any Medicare-approved healthcare provider that agrees to the plan’s specific terms and conditions. Some PFFSs have networks of providers who’ve agreed to always treat plan members. Before going out-of-network, a member should contact the provider to confirm they’ll provide treatment under that plan and accept its terms. If they don’t, the member is responsible for the cost of any care services they receive. PFFS plan members don’t need to choose a primary care doctor, and they don’t need referrals to see specialists. Some PFFSs cover prescription drugs and Medicare Part D can be added to those that don’t.
Special Needs Plans (SNP)
Medicare Advantage SNPs limit membership to those who have certain characteristics or diseases. For example, some plans require that members reside in nursing homes, some are for those dually eligible for Medicare and Medicaid, and others are for those with specific conditions, such as diabetes or end-stage renal disease. Each plan’s benefits, network, and drug formulary are tailored for those who meet its eligibility requirements. In most cases, members must choose a primary doctor, and referrals to see specialists are needed. All SNPs cover prescription drugs.
Enrollment & Eligibility for Medicare Advantage Plans in Illinois
To be eligible for Medicare Advantage, Illinois seniors must be at least 65 years old or have a disability, and they must be U.S. citizens or permanent residents. They must be enrolled in Original Medicare Parts A and B, and they have to live within their chosen plan’s service area. They also can’t be enrolled in Medigap insurance, as this coverage can’t be used with Medicare Advantage plans. Individuals receiving disability insurance must do so for 24 months in order to qualify for Medicare.
Illinois seniors who receive Social Security retirement benefits or Railroad Retirement Board benefits are automatically enrolled in Medicare Parts A and B upon turning 65. During the initial enrollment period that opens three months before the month of their birthday, they can switch to a Medicare Advantage plan.
Illinois seniors can only sign up for or make changes to their Medicare Advantage plans at specific times.
- The initial enrollment period lasts for a seven-month period, beginning three months before an individual turns 65 and extends three months beyond their birthday month. For SSDI beneficiaries, the period begins three months prior to their 25th month of receiving benefits.
- There are two enrollment periods each year, including an annual election period that runs from October 15th to December 7th and an open enrollment period that runs from January 1st to March 31st.
- A general enrollment period is open annually from April 1st to June 30th for those who have Medicare Part A, enrolled in Part B for the first time during the open enrollment period, and are switching to a Medicare Advantage plan.
- Special enrollment periods open for several circumstances, including when a member loses coverage due to moving, they become eligible for an SNP, or their plan’s contract with Medicare changes.
Prescription Drug Coverage
Illinois seniors have two options for getting prescription drug coverage. A Medicare Prescription Drug Plan, also called Part D, can be added to Original Medicare and some PFFS plans. Alternately, seniors can enroll in a Medicare Advantage plan that offers this coverage. These plans are sometimes called MA-PDs. Before signing up for an MA-PD, seniors who take prescription drugs should make sure that their medications are listed on the plan’s drug formulary.
Generally, seniors who opt for HMO and PPO plans should enroll in one that includes prescription drug coverage. If they sign up for separate Part D coverage, they’ll lose their Medicare Advantage plan and its extra benefits and go back to Original Medicare.
Medicare Advantage Resources in Illinois
Selecting the right Medicare Advantage plan is essential for getting the needed benefits while keeping medical costs affordable. Illinois seniors have many plans to choose from, and it can be difficult to plan for current and future health needs. To help older adults find the best coverage for their unique needs, Illinois has free and low-cost resources at the state and local level. Through these resources, seniors can learn about the different plans available to them and receive help with enrollment, filing claims, and the appeals process.
Illinois Department on Aging
The Illinois Department on Aging offers a wide array of direct services for seniors. Its Senior Health Insurance Program provides free statewide health insurance options counseling for Medicare beneficiaries. Program counselors help clients compare various Medicare Advantage plans, understand and reconcile billing statements, and navigate the appeals process for denied coverage. Its Senior Legal Assistance program provides legal services for Illinois residents aged 60 and over. It represents seniors in civil cases, including those pertaining to consumer fraud, conflicts over benefits programs, and financial exploitation. It also assists with simple estate planning, living wills, and powers of attorney.
Area Agencies on Aging
The Illinois Department on Aging oversees 13 Area Agencies on Aging to serve adults aged 60 and older. AAAs contract with local service providers and nonprofit organizations to provide services, such as information and assistance, well-being checks, meals, transportation, and legal help. Many of these services are offered through local senior centers, which facilitate various social, educational, and recreational programs for older adults. AAAs also give free, one-on-one Medicare options counseling for seniors through the Senior Health Insurance Program. Volunteer SHIP counselors answer questions about Medicare, help clients compare prescription discount cards, and resolve billing disputes between beneficiaries and Medicare.
CJE SeniorLife is a nonprofit organization based in Chicago that provides programs and resources for local seniors. It serves over 20,000 seniors and families in Chicago and the surrounding suburbs with a variety of services, such as independent and assisted living, home-delivered meals, transportation, health and wellness activities, and lifelong learning opportunities. It has three adult day care locations in the area where members can participate in activities such as creative arts therapy and dance. Its Consumer Assistance Resource Specialists provide benefits counseling, helping seniors identify and apply for government programs, including free transportation services, nutrition assistance, Medicare, Medicare Advantage, and prescription drug assistance.
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