The New Jersey Consumer’s Guide to 2011 Medicare Advantage
Choosing the Medicare plan appropriate to your needs can be a difficult and confusing process. The Annual Enrollment period was shortened this year and begins November 15th, ending December 31. It is ever more important to select the plan that is right for you. Medicare Solutions hopes to facilitate this process for you so that you pick a plan that fits what you need. Remember, it is imperative that you understand what you need in a Medicare plan and how that plan works.
Medicare is a program funded and administered by the federal government for seniors over the age of 65 and disabled people of any age. The program provides health insurance coverage for seniors. When enrolling in Medicare, you have several different options. The first is to choose the traditional Medicare program, which includes Part A hospital insurance and Part B outpatient health care and operates on a fee-for-service model. You do not generally pay a premium for Part A, but most people pay a premium of approximately $100 monthly.
Another choice for seniors in qualifying areas is the Medicare Advantage (Part C) program, which permits seniors to seek coverage through Medicare-approved private insurers. There are many different Advantage plans, and each has different benefits, premiums, and copayments. Advantage plans offer the same coverage as Part A and B, but also may include additional benefits like prescription drug coverage, vision, and dental care. Medicare Advantage plans may reduce health care costs, but are only available in specific regions of the United States.
If you would like prescription drug coverage, you should consider enrolling in a Part D prescription drug plan. Original Medicare does not include drug coverage; many Advantage plans already include Part D coverage. Medicare offers Part D plans through specific private insurance agencies. To qualify, you must be enrolled or entitled to Part A and B Medicare. However, Part D covers only medically necessary prescriptions, and you will most likely have to pay a monthly premium for the coverage.
If you are enrolled in original Medicare, consider adding a Medicare Supplemental Insurance plan. Medicare does not cover all health-related expenses, and supplemental—or Medigap—insurance policies can help fill in those gaps. There are 10 different Medigap plans that offer varying amounts of coverage depending on your personal needs. If you do opt to add a Medigap plan to your original Medicare, remember that you will need to pay an additional premium for the plan. If you are enrolled in Medicare Advantage, you will most likely not need to add supplemental insurance because Advantage plans generally fill in those gaps already.
Should I choose an Advantage plan?
There are three popular types of Medicare Advantage Plans available: HMO, HMO/POS, and PPO, all of which differ by cost, coverage, and network. Each plan works differently, so it is imperative that you understand the plan you choose. HMO plans tend to have very low premiums, but also may limit health provider choice to their network of providers. You must generally select a primary care provider from the network and seek referrals in order to see a specialist. The HMOs with the lowest premiums may also involve extensive copayments and coinsurance.
Advantage PPOs and HMO/POS are another option for seniors leaning towards an Advantage plan. Although these two plans may also incorporate preferred networks, they are not as limiting as HMO networks and offer greater flexibility for those who seek out-of-network help. If you travel often, a PPO or HMO/POS may be a perfect choice for you. These plans offer essentially the same benefits at an HMO, but may come with higher policy premiums and cost-sharing than HMO plans.
There are no private fee for service – or PFFS – plans available in 2011,as they are being phased out. This buying guide will only discuss MA plans that include prescription drug coverage as most seniors will need or have interest in plans with pharmacy benefits and, if you opt for an MA plan, you cannot purchase a standalone PDP plan.
New Jersey MA Plans in 2011
Horizon Blue Cross Blue Shield, United Healthcare, and Secure Horizons are the most well known companies offering MA plans in New Jersey. Seniors can select from at least 8 Medicare Advantage plans from these carriers.
Horizon BCBS has the broadest MA coverage, offering HMO and POS plans across the state in every county. United Healthcare offers 2 HMO/POS plans in the nine counties: Bergen, Essex, Hudson, Mercer, Middlesex, Monmouth, Ocean, Passaic and Union.
For 2011, United’s two HMO/POS plans have no monthly cost and offer out-of-network benefits. These plans are very competitive in the 9 counties offered. For seniors outside of these counties, Horizon’s HMO plans are a great alternative.
Financial Assistance
If you have limited income, you may be able to receive state help for paying your Medicare premiums. Options vary from state to state, but in New Jersey, the two major programs are PAAD and the Senior Gold Prescription Discount Program.
PAAD, or the Pharmaceutical Assistance to the Aged and Disabled, helps subsidize drug costs for low income New Jersey seniors. Prescriptions must be from a manufacturer who has agreed to New Jersey’s terms and regulations. Medications bought outside of New Jersey will also not be covered by PAAD. PAAD participants are not required to pay premiums for the Part D drug plan below a certain amount. If you qualify for PAAD, you also do not need to pay deductibles, coinsurance, or other costs yourself involving Part D. You will need to cover the $6 copayment for generic medication or $7 copay for covered brand name drugs.
If you live in the state of New Jersey, are over 65 years old, or receive Social Security disability benefits, you may qualify for PAAD. To enroll in PAAD, you must have an income that is less than $24.432 if you are single and $29.956 if you are part of a couple.
Another financial assistance program in New Jersey is the Senior Gold plan, which supplies insulin, diabetic testing equipment, and prescription drugs to eligible New Jersey citizens. If you enroll in Senior Gold, you will need to pay $15 for each prescription 50% of the prescription’s price. If you are in Senior Gold and your out-of-pocket expenses total over $2000 each year ($3000 for couples), you will have the full cost of your prescriptions paid for, except for the $15 copayment.
If you live in New Jersey and are older than 65, you may be eligible for Senior Gold. The qualifying income ranges are $24,432 - $34,432 if you are single and $29,956 - $39,956 if you are married.
Medicare Supplemental Insurance Plans
Traditional Medicare plans do not cover everything, and for seniors who want to expand coverage without enrolling in a Medicare Advantage plan, supplemental insurance may be the way to go. There are 8 plans currently available in 2011, all sold by private insurance agencies and designed to cover service gaps left behind by original Medicare. In 2010, two additional supplemental insurance plans became available, Plans M and N, with lower monthly premiums and increased cost sharing.
Supplemental insurance, or Medigap, plans may include high monthly premiums, but will also pay for services that are not completely covered by Medicare, diminishing your out-of-pocket expenses. Medigap policies may cover Part A or B premiums, coinsurance, or deductibles. However, these charges are unrelated to Advantage plans, employer or union insurance, VA benefits, or TRICARE insurance for the families of military personnel. Medigap plans do not include prescription drug coverage, so you would have to enroll in a separate Part D prescription drug plan.
Many insurance agencies in New Jersey offer Medigap plans, but two plans to take a close look at are offered by Mutual of Omaha/United World and Gerber. Both plans have well-priced monthly premiums: Mutual of Omaha/United World's Plan F has a $182.78 premium and Gerber's Plan G boasts a $160.81 premium in Passaic County, New Jersey for a male aged 65. The two plans, F and G, offer similar benefits. Again, Medigap plans do not include prescription drug coverage, so you would need to enroll in a separate Part D prescription medication plan. It's important to note that Plan N does not require medical underwriting.
Making the Decision
When identifying the health insurance plan that fits your needs best, you need to consider all of the available options in New Jersey. Create a budget of how much you are able to spend on health care and use that to determine the price that best fits your needs, especially when plan offer similar benefits for different prices. When choosing a supplement plan, remember that price is a major factor.
Medicare Advantage plans are more complex. While cost is also an important variable to consider, the additional benefits and coverage options are also incredibly important. Take into account the quality and broadness of health provider networks, your travel habits, and the terms of the provider’s plan.
You also need to take into account prescription drug packages, whether they are included with a Medicare Advantage Plan or part of a supplemental Part D prescription drug plan. You must also look at the drug formulary that may be associated with your plan to see if your prescriptions are included with the formulary.
Dates to Remember
- November 15 – Annual enrollment season begins
- December 31 – Annual enrollment season ends
Need help?
Medicare Solutions is here to help you select your Medicare plan. If you have any questions or concerns, navigate the Medicare Solutions site or give us a call at 1-877-270-0612 to speak with our trained experts.
