What You Need to Know
There are several types of MA plans in Delaware, including HMOs and PPOs.
In addition to their other benefits, MA plans typically include Medicare Part D prescription drug benefits.
Seventeen percent of everyone eligible for Medicare in The First State have signed up for an MA plan.
Delaware Medicare Advantage plans are bundled, all-in-one alternatives to Original Medicare. Also known as Medicare Part C, these plans provide your Medicare Part A and B benefits. MA plans typically also include Medicare Part D prescription drug benefits and additional benefits such as vision, hearing, and dental care.1
Medicare-approved private insurance companies sell MA plans, and the exact benefits vary by plan.
What Types of Medicare Advantage Plans Are Available?
There are several types of Delaware MA plans. One important factor in deciding on a plan type is whether it has a provider network and what the rules are concerning using it. A provider network is a group of doctors, healthcare providers, and facilities contracted with a health insurance plan.
Here are the types of MA plans available:
- Health maintenance organization (HMO): An HMO has a provider network, and you must go to a provider in the plan’s network to have your care covered. Exceptions are made for emergencies and if you’re traveling outside of your plan’s service area. You typically also need a referral to see a specialist. HMOs are the most common type of MA plan.2
- Preferred provider organization (PPO): A PPO also has a provider network. You can see out-of-network providers, but you pay less if you stay within the network. You typically do not need a referral to see a specialist.
- Private fee-for-service (PFFS) plan: This type of plan may not have a network. If there’s no network, you can visit any doctor who agrees to the plan’s terms and conditions.
- Special needs plans (SNPs): These plans are for Medicare members with specific healthcare needs. There are three types of SNPs:
- Chronic condition SNP (C-SNP): This kind of plan is for people with a specific health condition like cancer, autoimmune disorders, dementia, diabetes, end-stage renal disease (ESRD), and HIV/AIDS.
- Institutional SNP (I-SNP): This plan type is for people who live in a nursing home or need nursing care at home.
- Dual Eligible SNP (D-SNP): This plan is for people who are eligible for Medicare and Medicaid.
- Medical savings account (MSA) plan: This option combines a high-deductible MA plan with a medical savings account (MSA). The insurance plan deposits money into the MSA, which you can use to pay for covered Medicare costs. If you use all the money in your MSA and you haven’t met your deductible, you’re responsible for the costs. Once you reach your deductible, your plan will cover your Medicare-covered expenses.3
Having a Medicare Advantage plan can take the place of Original Medicare, a Medicare Supplement plan and a Medicare Part D plan for prescription drug coverage (check the plan to make sure Part D is covered).
What Are the Prescription Drug Options Available With Medicare Advantage?
Most MA plans include Medicare Part D, which is Medicare’s prescription drug coverage. MSA and some PFFS plans don’t include prescription drug coverage, but you can buy a separate Part D plan. If you join an HMO or PPO that doesn’t have Part D coverage, you cannot buy a separate Part D plan.
If you choose an MA plan without drug coverage and you don’t (or can’t) buy a separate Part D plan, you may pay a late enrollment penalty if you decide to buy one of the Medicare Part D plans at a later date.4
How Do You Choose a Medicare Advantage Plan?
To choose an MA plan, speak to a licensed professional or start by visiting the Medicare Plan Finder. Enter your ZIP code, preferred doctor(s), and prescriptions. You’ll get a list of potential plans in your part of Delaware.
Review each plan, looking at various factors:
- Premiums: More than half of all MA plans have a $0 monthly premium.5 From there, premiums vary. Keep in mind that you have to pay your Medicare Part B premium in addition to any premiums for your MA plan.
- Other costs: MA plans have costs beyond your premiums, which may include:
- Deductible: This is the amount you pay for Medicare-covered services before your plan starts paying.
- Copayment: This is a set dollar amount you pay for a service, such as $10 for a doctor’s visit.
- Coinsurance: This is a percentage you pay for a service after you pay any deductibles. For example, you might pay 20% of an emergency room visit.6
- Out-of-pocket maximum: This is the most you will pay out of pocket annually for your Medicare-covered services.7
- Benefits: These options vary by MA plan and may include:
When and How to Enroll in a Medicare Advantage Plan
You can only enroll in an MA plan at certain times.
- Initial Enrollment Period: You can enroll in an MA plan when you’re first eligible for Medicare. Most people become eligible for Medicare at age 65. You have a seven-month window that starts three months before the month you turn 65 and ends three months after your birthday month. If you’re on Medicare due to a disability and younger than 65, you’ll start Medicare Parts A and B after you’ve received Social Security benefits for 24 months. You’ll be able to enroll in an MA plan at that time.
- Open Enrollment Period (also known as your Annual Election Period): This period is from October 15 to December 7 each year. You can enroll, drop or switch MA plans at this time.
- Medicare Advantage Open Enrollment Period: This is from January 1 to March 31. If you have an MA plan, you can switch to another MA plan or drop your plan and return to Original Medicare.
- General Enrollment Period: This is also from January 1 to March 31. If you have Medicare Part A and start Medicare Part B during this time, you can join an MA plan. Your plan may not begin covering you until July 1, however.10
- Special Enrollment Period: You can also enroll in an MA plan in certain circumstances. These include:
- Changing service area: If you move out of your MA plan’s service area, you can switch to a new MA plan.
- Losing coverage: If you lose employer coverage or union health insurance, you can sign up for an MA plan.
- Plan changes: If Medicare terminates its contract with your MA plan, you can enroll in a new plan.
- Special circumstances: These situations include becoming eligible for Medicaid or developing a chronic condition that would be better served by a chronic condition special needs plan (C-SNP).11
What’s Medicare Advantage Plan Enrollment in Delaware?
The Delaware Medicare Advantage penetration rate is 17%. That means 17% of everyone eligible for Medicare in the First State has signed up for an MA plan.
How Much Do Medicare Advantage Plans Cost in Delaware?
The average cost for an MA plan in Delaware is $19.53 per month,12 which is lower than the national average of $21.13 In Wilmington, for example, Medicare beneficiaries can choose among 16 MA plans. Twelve of these plans have a $0 monthly premium. The rest range from $59 to $100 per month.
What Medicare Advantage Plans Cost
The average price of a plan’s monthly premium in Delaware is $19.53, which is lower than the national average of $21 per month. Some plans cost $0.
How Do You Change Your Medicare Advantage Plan?
You can change your MA plan between January 1 and March 31 each year. This is your Medicare Advantage Open Enrollment Period when you can change to another plan or drop your plan and switch back to Original Medicare.14
To change your plan, visit the Medicare Plan Finder or contact the plan you’re interested in selecting.
What Are Alternatives to a Medicare Advantage Plan?
One alternative to an MA plan is Original Medicare, which includes Medicare Parts A and B. On its own, Original Medicare has significant out-of-pocket costs — that is why people often buy an MA plan, which bundles Parts A and B along with other benefits. For example, MA plans often include Medicare Part D, which is prescription drug coverage.
If you want Original Medicare and help with out-of-pocket costs, you could buy a Medicare Supplement plan (also known as Medigap plans or policies). These plans can help with Part A deductibles and Part A and B copays and coinsurance.
Medicare Supplement insurance plans don’t include Part D prescription drug coverage. If you’d like that, you’ll need to purchase Part D coverage separately. So with Original Medicare, you could end up with three types of coverage (Medicare, a Medicare Supplement Plan, and a Part D plan) rather than an all-in-one MA plan.15
Another alternative coming soon to Delaware is PACE (Programs of All-Inclusive Care for the Elderly). PACE is an integrated program for individuals ages 55 and older who need assistance to continue living in their community rather than in a nursing home. Delaware is currently developing PACE.
What Are Medicare Resources in Delaware?
Delaware residents have access to a variety of Medicare Resources, including:
- The Delaware Medicare Assistance Bureau (DMAB): This program provides free health insurance counseling to Medicare members. Call 1-800-336-9500 to set up a counseling session.
- The Delaware Department of Insurance: If you have an issue with your MA plan, you can file a complaint online with this department.
- Delaware Medicaid: This program assists seniors with limited income and assets. Apply online here.
If you’re ready to find an MA plan, visit the Medicare Plan Finder or speak to a licensed professional. Review the costs and coverage options carefully, and don’t hesitate to ask questions of the insurance company. If you need assistance, contact the DMAB.