What You Need to Know
Medicare Advantage plans include everything that Original Medicare covers plus extra benefits.
If your Medicare Advantage HMO or PPO doesn’t cover prescription drugs, you can’t buy a standalone Part D plan.
Many plans in Hawaii have no deductibles or healthcare providers in your network.
Part of turning age 65 is signing up for Medicare. Do you know what options are available in Hawaii? Begin by brushing up on the alphabet soup of Medicare – Parts A, B, C, and D. Original Medicare consists of Part A (inpatient) and Part B (outpatient). Medicare Advantage bundles these two together. Here are some of the differences:
- The federal government runs Original Medicare. Private insurers offer Medicare Advantage plans.
- Most MA plans provide extra benefits that Original Medicare doesn’t include.
- Unlike Original Medicare, MA plans cap annual out-of-pocket costs.
What Types of Medicare Advantage Plans Are Available?
Health Maintenance Organization (HMO) plans offer lower premiums compared to other plans. You can only go to providers in the network, except for emergencies. And you need a referral from your primary care provider to see a specialist.
Preferred Provider Organization (PPO) plans have more flexibility. You can go to out-of-network providers, but you pay more when you do so. You don’t need a referral to see a specialist.
Special Needs Plans (SNPs) target care for specific needs, including:
- Those with chronic health conditions (C-SNP),
- Dual eligibility for Medicare and Medicaid (D-SNP),
- Those requiring institutional care in a skilled nursing facility, or other type of long-term care (I-SNP).
Private Fee-For-Service (PFFS) plans choose how much the plan will pay healthcare providers and how much you will pay out of pocket. You can go to any Medicare-approved provider that accepts the plan’s payment terms and agrees to treat you. Not all providers will.
Medicare Savings Accounts (MSAs) are high-deductible plans combined with a medical savings account. The plan deposits money into a bank account which you use to pay for medical services before you meet your deductible. Once met, your plan pays covered expenses.
Your Medicare Advantage plan may include benefits such as vision and dental coverage.
What Are Prescription Drug Options with Medicare Advantage?
- Most Medicare Advantage HMO and PPO plans include Medicare Part D. But if yours doesn’t, you can’t enroll in a separate Part D plan.
- All SNP plans cover prescription medications.
- If your MSA or PFFS plan doesn’t offer coverage, you can enroll in a separate Part D plan.
How Do You Choose Medicare Advantage Plans?
Plans in Hawaii include HMOs, PPOs, and MSAs, many with 5-star ratings. However, the range of options vary by county. For example, there are 15 plans in Honolulu County but only seven in Hawaii County.2
How do you decide on the plan that’s best for you? Cost and coverage are key factors in choosing any health insurance plan. Here’s what to look for when evaluating your options.
The premium is the amount you pay each month for your plan. In addition to the Medicare Advantage premium, you must also pay the Part B premium. In 2021, the Part B premium is $148.50 for most people.3 Some higher-income seniors pay more.
In Hawaii, you can get a zero-premium plan. But you are still responsible for the Part B premium. In addition, you may have higher out-of-pocket costs when you need care compared to other plans.
- Coinsurance is a percentage of the cost for services you pay once you meet your deductible.
- Copayments are fixed amounts you pay for office visits and/or prescription drugs.
- Deductible is the amount you must spend before your plan starts to contribute toward your healthcare expenses.
- Out-of-pocket maximum is the highest amount you’re required to pay during the plan year.
Consider All Costs
If you choose a zero-premium plan, your out-of-pocket costs when you need care may be higher than other plans.
Medicare Advantage plans often provide benefits that Original Medicare does not. These may include coverage for vision, dental, hearing, transportation, and telehealth services. Some even include access to gyms or fitness programs.
When and How to Enroll in Medicare Advantage
You must enroll in Medicare Part A and B before you can enroll in an MA plan. You’ll need to do so during the appropriate enrollment period.
Initial Enrollment Period: The seven-month period beginning three months before, the month of, and the three months after your 65th birthday.
Open Enrollment Period (Annual Election Period): October 15 through December 7 annually. You can change MA plans, switch between MA and Original Medicare plans, and enroll in a Part D plan.
General Enrollment Period: January 1 through March 31 annually with coverage beginning July 1.
Medicare Advantage Open Enrollment Period: If you enrolled in Medicare during the General Enrollment Period, you may enroll in an MA plan from April through June with coverage beginning July 1.
Special Enrollment Period: Under certain circumstances, you may be able to enroll outside the scheduled periods without incurring a penalty:
- Change of service area – includes moving out of the provider network.
- Loss of coverage – such as losing coverage under Medicaid or an employer’s plan.
- Gain coverage – such as qualifying for group coverage under an employer or union plan.
- Plan changes – if your plan’s contract is terminated by Medicare.
- Special circumstances – such as development of a chronic condition which qualifies you for a C-SNP.
What’s the Medicare Advantage Enrollment in Hawaii?
As of April 2021, 130,000 Hawaii residents were enrolled in MA plans. That represents 45% of all Medicare-eligible individuals.
How Much Do Medicare Advantage Plans Cost in Hawaii?
Monthly premiums range from zero to $196, not including the Part B premium.4
- Health deductibles are zero for most plans.
- Drug deductibles range from zero to $445.
- Primary care visit copays on most plans range from zero to $30.
- Specialist visit copays on most plans range from zero to $50.
How Do You Change Your Medicare Advantage Plan?
You can either change to a different MA plan or switch between Original Medicare and an MA plan during Open Enrollment or General Enrollment periods.
What Are Alternatives to Medicare Advantage?
- Original Medicare, which includes Part A and B only.
- Original Medicare with a Medigap policy that covers out-of-pocket expenses for Part A and B services.
- Original Medicare with a Medigap plan and a Part D plan.
Medicare Advantage plans are similar to Original Medicare with a Medigap policy and a Part D plan, but there are differences. One advantage to MA plans is that they bundle all policies, eliminating the need to manage multiple plans. You would buy coverage from private insurers for either option.
What Are Medicare Resources in Hawaii?
Med-Quest Medicaid and Medicare Integration Plans – provides information about integrating Hawaii Medicare and Medicaid coverage for low-income elderly and the disabled.
State Health Insurance Assistance Program (SHIP) – provides free information and assistance to help you choose Medicare coverage.
Now that you’ve done your homework about Medicare Advantage, it’s time to compare plans available in Hawaii. Speak to a licensed professional for tips and guidance on plans. You can also use the Medicare Plan Finder to determine which plan suits your needs and your budget.