Medicare Advantage Plans in New Jersey

Medicare Advantage plans are an alternative to Original Medicare, offered by Medicare-approved private insurance companies. These plans bundle Part A (hospital coverage) and Part B (medical coverage), and most also include Part D (prescription drug coverage). Many plans offer additional benefits like dental, vision, hearing, fitness programs, and transportation services.

Medicare Eligibility

To enroll in a Medicare Advantage plan, you must first enroll in Original Medicare (Parts A and B). Most individuals become eligible for Medicare enrollment at age 65, but people with certain disabilities, ALS, or ESRD may qualify earlier. Enrollment opportunities include:

• Initial Enrollment Period (IEP)
• General Enrollment Period (GEP)
• Special Enrollment Periods (SEP)

Failure to enroll during the appropriate window may result in late penalties or loss of access to premium-free Part A.

What Types of Medicare Advantage Plans Are Available in New Jersey?

New Jersey offers several Medicare Advantage plan types:

• Health Maintenance Organizations (HMOs): Require the use of in-network providers and a primary care physician (PCP); referrals typically needed for specialists.
• Preferred Provider Organizations (PPOs): Allow visits to both in- and out-of-network providers, with lower costs in-network and usually no referral requirements.
• Private Fee-for-Service (PFFS) Plans: Let you visit any provider that accepts the plan’s payment terms. Some have networks but don’t require a PCP.
• Special Needs Plans (SNPs):
  • C-SNPs: Designed for individuals with chronic conditions such as cancer, diabetes, or heart disease.
  • I-SNPs: For people living in institutions or requiring skilled nursing care at home.
  • Dual Eligible Special Needs Plans (D-SNPs): For those eligible for both Medicare and Medicaid, offering coordinated care, prescription drug coverage, and other services at low or no cost.
• Medical Savings Accounts (MSAs): Combine a high-deductible health plan with a savings account funded by your insurer for qualified medical expenses.

What Are Your Prescription Drug Options with Medicare Advantage?

Most MA plans in New Jersey include Part D drug coverage. However, plans such as MSAs and certain PFFS plans do not.

If your plan doesn’t include drug coverage:

• You may be able to enroll in a standalone Part D plan (depending on the plan type).
• You may face a late enrollment penalty if you go without creditable drug coverage.

How Do You Choose a Medicare Advantage Plan?

Understanding Medicare Advantage costs can help you select the right plan:

• Premiums: Many plans offer $0 premiums, but others may have a monthly fee.
• Deductibles, Copays & Coinsurance: Costs vary by plan. For example, you may pay fixed copays for doctor visits or a percentage of costs for specialist care.
• Out-of-Pocket Maximums: Annual limits help protect you from excessive healthcare costs. These limits typically range from $3,000 to $8,000 for in-network care.
• Extra Benefits: Some plans include vision and dental coverage, telehealth, transportation, over-the-counter allowances, and gym memberships.

When and How Do You Enroll in a Medicare Advantage Plan?

You can enroll in Medicare during the following specific enrollment periods:

• Initial Enrollment: Starts 3 months before and ends 3 months after your 65th birthday month.
• Annual Open Enrollment (Oct 15–Dec 7): Switch, join, or drop MA plans.
• General Enrollment (Jan 1–Mar 31): For people enrolling in Medicare Part B during this timeframe.
• Medicare Advantage Open Enrollment (Jan 1–Mar 31): For those already enrolled in MA to switch plans or return to Original Medicare.
• Special Enrollment Periods: Available in cases such as:
  • Moving out of your plan’s service area
  • Losing employer or union coverage
  • Becoming ineligible for Medicaid
  • Plan termination
  • Being diagnosed with a condition qualifying you for an SNP

What If You Want to Change Your Medicare Advantage Plan?

You can switch plans during:

• Annual Open Enrollment (Oct 15–Dec 7)
• Medicare Advantage Open Enrollment (Jan 1–Mar 31)

New coverage begins once the new plan takes effect. You’re automatically disenrolled from your old plan upon enrollment in a new one.

What Are Medicare Resources in New Jersey?

New Jersey offers several helpful programs for Medicare beneficiaries:

• New Jersey SHIP (State Health Insurance Assistance Program): Offers free, unbiased counseling on Medicare plans and enrollment.
• New Jersey SMP (Senior Medicare Patrol): Educates beneficiaries on detecting and preventing Medicare fraud.
• New Jersey Department of Banking and Insurance: Handles insurance complaints and coverage issues.
• NJ FamilyCare: New Jersey’s Medicaid program, offering assistance for eligible low-income residents. Call 1-800-701-0710 or visit the website for more details.

Learn more about the differences between Medicare and Medicaid.

Understanding Medicare Advantage Star Ratings

The CMS star ratings system is how the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (MA) plans using a 5-star quality scale. These ratings help consumers compare the performance of different plans based on a standardized set of measures.

CMS Star Ratings Overview

• 1 star: Poor performance
• 2 stars: Below average
• 3 stars: Average
• 4 stars: Above average
• 5 stars: Excellent

These ratings are updated annually and reflect data collected from Medicare Advantage (Part C) and Medicare Advantage Prescription Drug Plans (Part D).

Other Medicare Plan Options to Help with Out-of-Pocket Costs

Medicare Supplement Plans, or Medigap, are standardized policies sold by private insurers to help cover deductibles, copayments, and coinsurance left by Original Medicare.

• You must have Medicare Parts A and B to enroll in Medigap.
• The best time to enroll is during your six-month Medigap Open Enrollment Period, which begins once you sign up for Part B.
• After this period, medical underwriting may be required.
• Medigap does not include drug coverage—you’ll need a separate Part D plan.

There are 10 Medigap plans. Medicare Supplement Plan G had the highest enrollment in 2023, and Plans G and N are the fastest growing. Plan F is not available to new Medicare enrollees as of 2020.

Learn more about Medicare Supplement plans in New Jersey.

Next Steps

If a Medicare Advantage plan in New Jersey suits your needs, begin comparing plans available in your ZIP code. Review provider networks, drug formularies, premiums, and extra benefits to choose the plan that aligns with your health and budget. Be ready to enroll during your eligible window.