As your 65th birthday approaches, one decision you’ll have to make is choosing healthcare coverage: Will you be covered by Original Medicare (Medicare Part A and B)? Or will it be a Medicare Advantage plan (also called Part C)?
What You Need to Know:
Most Medicare Advantage health maintenance organizations (HMOs) and preferred provider organizations (PPOs) and all special needs plans (SNPs) cover prescription drugs.
Every year, there are multiple enrollment periods when you can join a Medicare Advantage plan.
What Types of Medicare Advantage Plans Are Available in Georgia?
Georgia has 63 Medicare Advantage plans,3 divided among four different types: HMOs, PPOs, SNPs and PFFS. Here are the pros and cons of each:
- Health maintenance organization (HMO)
HMO premiums (the amount you pay monthly to have coverage) are usually the lowest among Medicare Advantage plans. Except for emergencies, you’ll be limited to seeing providers within your HMO’s network and you’ll need to have a primary care physician who oversees referrals to see a specialist.4
- Preferred provider organization (PPO)
A PPO’s network of providers tends to be larger than for HMOs. Your premium will be higher, but you can see doctors out-of-network and still get some costs covered. You probably won’t need a primary care physician or referrals to see specialists.5
- Special needs plans (SNP)
SNP plans are designed for people with specific ongoing health conditions or disabilities or those who live in an institution. Care must come from your SNP network except in an emergency. You will have a primary care doctor or a care coordinator who provides referrals to most specialists. You can join a SNP at any time.6
The three types of SNPs in Georgia are:7
Chronic condition (C-SNP) – if you have one or more chronic or disabling conditions.
Institutional (I-SNP) – if you live in an institution, such as a nursing home, or you require nursing care at home.
Dual eligible (D-SNP) – if you’re eligible for both Medicare and Medicaid.
- Private fee-for-service (PFFS)
PFFS plans have the most flexibility of all Medicare Advantage plans. You may pay less to see an in-network provider, but you’re free to get care from any provider that agrees to your plan’s payment terms. And you won’t need a primary care physician or referrals to see a specialist.8
Medical Savings Account (MSA) plans are not available in Georgia.9
How Can You Get Prescription Drug Coverage with Medicare Advantage?
Original Medicare doesn’t include any prescription drug coverage, so people who choose it often buy a private, standalone Medicare Part D drug plan. Most Medicare Advantage HMOs and PPOs and all SNPs cover prescription drugs.
Be sure that any HMO or PPO you’re considering covers prescription drugs if you want that coverage, because you will lose your Medicare Advantage plan if you buy medication coverage separately. That said, PFFS plans don’t necessarily have drug coverage, so you can buy Part D coverage if you choose that type of plan.
How Do You Choose a Medicare Advantage Plan in Georgia?
First, see what plans are available in your area. Then look at the costs involved for any plans that seem like a good fit, what benefits are included and how much of your healthcare expenses are covered.
Premium: A Medicare Advantage plan can have two premiums you pay monthly: the premium for your Medicare Part B coverage and the premium for your Medicare Advantage plan. Some Medicare Advantage plans, though, are zero-premium plans, while others have premiums that vary with the amounts of coinsurance and copayments your plan covers, plus deductibles and the out-of-pocket maximum (limit).
Here’s what you need to know about these other costs:10
Deductible: The amount you need to pay for covered healthcare services before your insurance company starts picking up some or all of your expenses. (Remember that not all payments you make necessarily apply to your deductible.)
Coinsurance: The percentage of the cost you have to pay for a service covered by your plan after you’ve met your deductible. For example, your plan’s coinsurance could be 20%, which means you pay 20% and the insurance company pays 80% of covered expenses, but only after your annual deductible is paid in full.
Copayment (copay): A set amount (for example, $20) you pay for a covered service or prescription drug. The amount of a copay depends on the type of service or drug.
Out-of-pocket maximum: This is the most money you’ll need to pay in a single year for any service covered by your plan.
Medicare Advantage covers everything that Original Medicare covers, including inpatient hospital and skilled nursing facility care, emergency and urgent care, doctor’s visits, surgery, preventive care and some vaccines and medical equipment.
In addition, there may be other benefits. These vary from insurer to insurer and even within the same insurer and can include:
- Prescription drug coverage
- Vision care, such as eye exams and glasses
- Dental care, such as cleanings
- Hearing aids
- Gym membership
- Telehealth visits with providers
- Over-the-counter healthcare products
- Meals, such as meal delivery
When and How Do You Enroll in a Medicare Advantage Plan in Georgia?
Unless you have other insurance coverage (such as through your job), you’ll enroll in Original Medicare (Parts A and B) in the seven months around your 65th birthday. After that, you can decide to switch from Original Medicare to Medicare Advantage (Part C) and add drug coverage with a Part D plan, if you’re able. (SNP plans may have additional requirements.)
With Part C plans, you must live in the plan’s service area, and you must be a U.S. citizen or permanent legal resident who has lived in the U.S. for five straight years. You cannot have End-Stage Renal Disease (ESRD).11
Initial Enrollment Period (IEP): This enrollment period is based on your birthday: You can sign up during the seven-month period that starts three months before the month you turn 65 and ends three months after the month of that birthday. Enrollment during IEP is available to everyone who has Original Medicare.
Annual Election Period (AEP): This is also called “Open Enrollment” and runs from October 15 through December 7 each year. (It shouldn’t be confused with the OEP, explained below.) Anyone can enroll in a Medicare Advantage plan for the first time during this period or switch to a different Medicare Advantage plan.
Medicare Advantage Open Enrollment Period (OEP): Every year between January 1 and March 31 you have a second chance to decide on Medicare Advantage. You can change to a new Medicare Advantage plan or switch back to Original Medicare. If you go back to Original Medicare, you can also enroll in a standalone Part D prescription drug plan.
General Enrollment Period (GEP): If you enrolled in Medicare Part B for the first time during the Medicare Advantage Open Enrollment Period (January 1 through March 31), you can join a Medicare Advantage plan anytime between April 1 and June 30 of that same year.
Special Enrollment Period (SEP): In certain situations, such as losing the health insurance you had at your job, you can make changes to your Medicare Advantage plan outside of regular enrollment periods.13
How Much Do Medicare Advantage Plans Cost in Georgia?
In 2020, the average monthly premium in the U.S. for a Medicare Advantage plan was $23.63. In Georgia, it was $14.77, which was down by more than one-third compared to 2016. The estimate for 2021 is similar to 2020, at $14.84 per month.14
The cost of Medicare Advantage coverage depends on your plan type and where you live. As examples, Atlanta15 and Valdosta16 offer 50 and seven Medicare Advantage plans, respectively. For 2021, premiums range from zero to $90 in Atlanta and from zero to $87 in Valdosta.
When you get a quote for a Medicare Advantage plan (which you can do easily online), remember that this might not include any help you get from Medicaid, Supplemental Security Income, Medicare Savings Program or Extra Help from Social Security. For a more precise idea of how much each plan will cover and what it will cost, specify any help you currently receive, as well as the medications you’re taking.
As mentioned above, your monthly premium isn’t your only cost, though there are limits to what you’d need to pay out-of-pocket. In 2020, for Medicare Advantage HMO enrollees nationwide, the average annual out-of-pocket limit for in-network services was $4,486.17 (These plans don’t cover any services you receive from out-of-network providers.)
Medicare Advantage PPOs cover limited territories and can be local or regional. A local PPO’s network will cover one or more counties; a regional PPO’s network can extend to one or more states. The national average annual out-of-pocket limit for each (for in-network and out-of-network services combined) was $8,795 (local PPOs) and $9,010 (regional PPOs).18
These out-of-pocket limits apply to Medicare Part A and B services only and not to Part D (prescription drug coverage) costs.19
What Are the Alternatives to Medicare Advantage?
In some states, Programs of All-Inclusive Care for the Elderly (PACE) help you stay in the community rather than move into a nursing home, but these programs aren’t available in Georgia.20
The primary alternative to Medicare Advantage is to stay with the federal government’s Original Medicare program with Part A (hospital insurance) and Part B (medical insurance).
And you can buy a Medicare supplement (or “Medigap”) policy from a private insurer to cover expenses that Original Medicare does not. You also might want a standalone prescription drug plan (Medicare Part D), whether you opt for a Medigap policy or not.
What Medicare Resources Are Available in Georgia?
GeorgiaCares is the State Health Insurance Assistance Program (SHIP) that provides free and unbiased information on Medicare, Medicaid and other related health insurance. You can call (866) 552-4464 and choose option 4, or visit GeorgiaCares SHIP to learn more.
Two Medicare Savings Programs in Georgia can help people living on a limited income pay for the cost of having Medicare: Qualified Medicare Beneficiary (QMB) and Specified Low Income Medicare Beneficiary (SLIMB).21 They can help pay for your premiums, deductibles and other out-of-pocket health costs. Call (877) 423-4746, or visit your local Division of Family & Children Services office for an application (Form 700) or apply online.
Once you’re enrolled in Medicare Part A and Part B, consult the Medicare Plan Finder to find a Medicare Advantage Plan in Georgia. You’ll get a complete list of the plans available in your ZIP code after answering just a few questions. And you can also get all cost information on premiums, deductibles, copays and out-of-pocket limits.
With that information, you’re ready to compare coverage and benefits with the costs to choose the Medicare Advantage plan that’s right for you.