What Are Medicare Advantage Plans in Vermont?

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

Medicare Eligibility

To enroll in a Medicare Advantage plan, you must first sign up for Original Medicare (Parts A and B). Most people become eligible for Medicare enrollment at age 65, although individuals with certain disabilities or conditions like ALS or ESRD may qualify earlier. It’s important to understand the enrollment windows:

• Initial Enrollment
• General Enrollment
• Special Enrollment

Missing these periods could lead to late penalties or coverage gaps.

What Types of Medicare Advantage Plans Are Available in Vermont?

Vermont residents can access several types of MA plans:

• Health Maintenance Organizations (HMOs): Lower premiums, in-network care only, and referrals needed for specialists.
• Preferred Provider Organizations (PPOs): Higher flexibility with out-of-network access at additional cost; usually no referrals required.
• Private Fee-for-Service (PFFS): Any provider that agrees to the plan’s terms can be used; some plans may have a provider network.
• Special Needs Plans (SNPs): Tailored for specific populations:
  • C-SNPs: For chronic conditions like diabetes, HIV/AIDS, or heart disease.
  • I-SNPs: For individuals requiring nursing home or institutional care.
  • Dual Eligible Special Needs Plans (D-SNPs): For those eligible for both Medicare and Medicaid; these plans offer extra services at little to no cost.
• Medical Savings Accounts (MSAs): Combine a high-deductible plan with a medical savings account funded by the plan provider.

What Are Your Prescription Drug Options with Medicare Advantage?

Most MA plans include Part D drug coverage. However, MSAs and some PFFS plans do not. If your MA plan does not include drug coverage:

• You may be able to enroll in a separate Part D plan (only allowed with some plans).
• You could face a late enrollment penalty if you delay signing up and lack creditable coverage.

How Do You Choose a Medicare Advantage Plan?

Understanding Medicare Advantage costs can help you make the right choice. Consider:

• Premiums: Some plans offer $0 premiums, but you must still pay your Part B premium.
• Deductibles, Coinsurance & Copays: These impact what you’ll pay for services.
• Out-of-Pocket Maximums: MA plans include a yearly spending cap.
• Extra Benefits: Many include services not covered by Original Medicare—such as dental, vision, fitness, telehealth, and OTC allowances.

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

You can enroll in Medicare during specific enrollment periods:

• Initial Enrollment: 3 months before through 3 months after your 65th birthday.
• Annual Open Enrollment (Oct 15–Dec 7): Join, switch, or drop a plan.
• General Enrollment (Jan 1–Mar 31): For those enrolling in Medicare Part B.
• Medicare Advantage Open Enrollment (Jan 1–Mar 31): Switch MA plans or return to Original Medicare.
• Special Enrollment Periods: Triggered by life events like:
  • Moving
  • Loss of employer/union coverage
  • Medicare plan termination
  • Developing a qualifying condition for an SNP

What If You Want to Change Your Medicare Advantage Plan?

You can make changes during:

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

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).

What Are Medicare Resources in Vermont?

• Vermont State Health Insurance Program (SHIP): Free counseling on Medicare options.
• Vermont Senior Medicare Patrol (SMP): Helps beneficiaries prevent healthcare fraud.
• Vermont Department of Financial Regulation: Handles insurance-related complaints.
• Vermont Medicaid Program: Offers assistance for low-income residents. Visit https://dvha.vermont.gov/ or call 1-800-250-8427.
• Learn more about the differences between Medicare and Medicaid.

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

Medicare Supplement Plans, also called Medigap, help cover costs that Original Medicare doesn’t, such as deductibles and coinsurance.

• You must have Medicare Parts A and B to purchase a Medigap plan.
• The best time to enroll is during your six-month Medigap Open Enrollment Period.
• These plans do not include drug coverage, so you’ll need a separate Part D plan.
• There are 10 standardized plans; the most popular are F, G, and N.
• Medicare Supplement Plan G had the highest enrollment in 2023 and continues to grow.
• Plan F is no longer available to those newly eligible after January 1, 2020.

Learn more about Medicare Supplement plans in Vermont.

Next Steps

If a Medicare Advantage plan in Vermont suits your needs, explore plan options in your area. Compare benefits, provider networks, and out-of-pocket costs. Then, prepare to enroll during your eligible window.