What You Need to Know
Medicare Advantage plans include everything Original Medicare covers.
If you’re a snowbird, you may want to choose a plan that allows you to see out-of-network providers.
Unlike Original Medicare, Medicare Advantage caps your annual healthcare out-of-pocket expenses.
If you’re approaching age 65, or if you have already arrived, Medicare should be on your mind. If you live in the Green Mountain State, one of the options to consider is a Medicare Advantage (MA) plan. Medicare Advantage plans, also known as Part C, are offered by private insurers. They cover everything that Original Medicare does. But in addition to Medicare Part A and Part B, most MA plans offer additional benefits. And 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 emergency situations. You must pick a primary care provider (PCP) who coordinates your care. You need a referral from your primary care provider to see a specialist.
Health Maintenance Organization Point of Service (HMO-POS) plans require you to choose a PCP and get a referral to see a specialist. You can go to out-of-network providers, although you’ll pay more for doing so.
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 to choose a PCP or get a referral to see a specialist.
Special Needs Plans (SNPs) tailor care for individuals with specific needs, including:
- Those with chronic health conditions (C-SNP),
- Dual eligibility for Medicare and Medicaid (D-SNP),
- Those requiring institutional care in skilled nursing facilities or other types 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 doctor, other health care provider, or hospital 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 Medicare-covered services before you meet your deductible. Once met, your plan pays covered expenses.
Timing is Key
Don’t miss the enrollment dates for Medicare and Medicare Advantage. You can only enroll or switch plans during certain windows of time.
What Are Prescription Drug Plan Options with Medicare Advantage?
Your options depend on your plan. All SNPs provide prescription drug coverage. Most Medicare Advantage HMO, HMO-POS, and PPO plans include prescription drug coverage, known as Medicare Part D.1 But if your HMO or PPO plan doesn’t, you can’t enroll in a separate Part D plan. You can enroll in a standalone Medicare Part D plan if you have a PFFS or MSA plan.
How Do You Choose Medicare Advantage Plans?
Cost and coverage are key factors in choosing any health insurance plan, so consider premium costs, other costs, plan benefits, and network services.
Your premium is the amount you pay each month for the plan. Eight of the 19 MA plans available in Vermont are zero-premium plans. While these plans sound like they’re free, you will still be responsible for the Medicare Part B premium. You may also have a higher deductible and other out-of-pocket costs with a zero-premium plan.
- 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 obligation is the highest amount you’re required to pay during the plan year.
Medicare Advantage plans often provide benefits 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.
Most Medicare Advantage plans offer benefits that aren’t included in Original Medicare.
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. Choose 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 insurance company’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 Vermont?
Roughly 21,000 Vermont residents are enrolled in MA plans. They represent 13% of all Medicare beneficiaries in the state.
How Much Do Medicare Advantage Plans Cost in Vermont?
Monthly premiums for MA plans in Vermont range from zero to $140, not including the Part B premium.2 Most people pay $148.50 a month for Part B, though higher-income seniors may pay more.3 Plan options include HMOs, HMO-POS, PPOs, and MSA plans.
As an example, if you enroll in an HMO-POS plan with a $40 premium, you pay that amount, plus the Part B premium for a total monthly payment of $188.50. You pay additional costs when you get care. If you get care outside your network, you pay more for those services than you would in your network.
How Do You Change Your Medicare Advantage Plan?
If you’re already enrolled in Medicare Advantage, you can make a change during Open Enrollment or General Enrollment periods. You can switch to a different MA plan or drop your MA plan and join Original Medicare.
What Are Alternatives to Medicare Advantage?
The alternative to an MA plan in Vermont is Original Medicare, which includes Part A and B only. Many who choose this plan also enroll in a Medicare Part D for prescription drug coverage. Many also purchase a Medigap policy from private insurers to pay for uncovered expenses.
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.
What Are Medicare Resources in Vermont?
Vermont Health Connect Plan – provides information about moving from a Vermont Health Connect Plan to Medicare.
Medicare Savings Program – provides information regarding assistance available to pay for Medicare plans.
Vermont State Health Insurance Program (SHIP) – provides free information and assistance to help you choose Medicare coverage.
Now that you’ve learned more about Medicare Advantage plans in Vermont, it’s time to decide what type of coverage will work best for you. Speak with a licensed professional or view your options at the government’s Medicare Plan Finder.