Medicare Advantage Plans in Colorado
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: October 19, 2020
Original Medicare consists of two parts, A and B. Medicare Part A covers hospital expenses and skilled nursing care, including hospice and some home care. Part B handles doctor's visits, medical supplies, and outpatient treatments. Medicare Advantage (also called Medicare Part C) pays for the same medical expenses as Part A and B of Original Medicare; however, some plans also cover prescription drugs, dental, and vision claims. Private insurance companies manage Medicare Advantage plans, and premiums may be higher to account for the extra coverage and service.
- 1 In 2019, there were 49 Medicare Advantage plans available in Colorado.
- 2 36% of the total Medicare population in Colorado is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $8,765 per beneficiary in Colorado, which is 13% lower than the national average.
- 4 Available Medicare Advantage plans range from two to 49 across Colorado’s 64 counties.
If you’ve had employer-sponsored health insurance, you might not have much experience choosing a health care plan. Medicare Advantage plans can vary greatly in scope of coverage and premium amounts. Additionally, select regions throughout Colorado could have differences in plan availability. To ensure you make the right decision regarding healthcare benefits, carefully consider your health needs and budget before enrolling in a Medicare Advantage plan.
Medicare Advantage Plans in Colorado
Types of Medicare Advantage Plans
Like most states, Colorado offers four types of Medicare Advantage plans, usually abbreviated into letter acronyms. Select guidelines influence the way the plans are managed and what aspects of care they cover. Colorado’s Medicare Advantage program provides a wealth of choices for seniors, from premiums and deductible options to doctor selection.
Health Maintenance Organizations (HMO)
When you think about HMO plans, think in-network. In other words, any medical care (with the exception of emergency situations, urgent care, or out-of-the-area dialysis) you require must come from providers that are in the plan’s network. Your Medicare Advantage plan will expect you to choose an in-network primary care doctor to handle all your routine visits. Any specialist visits will usually need a referral. In rare cases, some HMO plans may let you choose an out-of-network provider, but you will pay more for treatment and service. Many HMO plans cover prescription drugs, but double-check before enrolling.
Preferred Provider Organizations (PPO)
Staying in-network is still important if you have a PPO plan, which has a designated network of providers, including doctors, hospitals, and pharmacies. Although you have more leeway to stray out-of-network with a PPO, you will usually pay more for the treatment or service. You also don’t need to designate a primary care doctor or need a referral, especially if you use a specialist in the plan’s network. PPOs usually cover prescription drugs, but it’s best to make sure before enrolling.
Private Fee-For-Service Plans (PFFS)
Some PFFS plans have provider networks, while others do not. As is commonly the case, if there is a provider network, you should use it to receive care at the lowest rate. If you visit an out-of-network doctor, your costs may be more, sometimes significantly. You won’t need a primary care doctor or a referral to a specialist with a PFFS plan, but be aware that sometimes out-of-network providers may refuse to see you if they don’t like the insurer’s compensation rate. If you take prescription medication, make sure that your PFFS plan of choice covers prescription drugs.
Special Needs Plans (SNP)
Designed to serve people with certain disorders or disease characteristics, SNPs have a limited membership base. The plans set up their provider network and drug formularies to best meet the needs of their members — those who live in nursing facilities, receive at-home nursing care or have certain diagnoses. Typical chronic conditions often within the scope of an SNP are diabetes, End-Stage-Renal Disease, HIV/AIDS, or dementia. If you enroll in an SNP, you will probably need to specify a primary care doctor or health care coordinator. All SNPs must provide coverage for prescription medications.
Enrollment & Eligibility for Medicare Advantage Plans in Colorado
Seniors must meet specific requirements to enroll in any of the Medicare Advantage plans throughout Colorado. First, you must already have Original Medicare Part A and Part B, which means you’ve met one of these requirements:
- Over the age of 65
- Have been receiving disability benefits for at least 24 months
Furthermore, you must also not have a Medigap insurance policy or End-Stage Renal Disease (ESRD), unless you plan to sign up for an SNP. Plan offerings across Colorado will vary according to zip code, and you must reside in the plan’s service area to enroll.
To ensure you don’t miss the opportunity to sign up for your chosen Medicare Advantage plan, you’ll want to keep careful track of the open enrollment periods.
- Seniors who are newly eligible for Original Medicare can enroll in the seven months surrounding their birthday month. This includes the three months before, the birthday month, and three months afterward. If you’re eligible due to a disability and are receiving SSDI benefits, your seven month period is based on the 25th month you receive benefits.
- Every year Medicare offers an open enrollment period, from October 15th to December 31st, for Original Medicare participants. During this time, seniors can enroll in Medicare Advantage plans and also switch plans.
- Current Medicare Advantage plan holders also have an additional time span to change or quit their Medicare Advantage plans. This Medicare Advantage open enrollment period takes place every year between January 1st and March 31st.
- Finally, if as a newly eligible individual, you missed your seven-month period of initial enrollment for Original Medicare, you have another opportunity to enroll during the Medicare general enrollment period. This occurs from January 1st to March 31st. After you’ve completed this process, you then have a special open window to enroll in a Medicare Advantage plan from April 1st to June 30th.
Prescription Drug Coverage
Prescription drugs can be a significant cost factor for seniors. Statistics gathered by the Kaiser Family Foundation show that almost 90% of seniors over the age of 65 take prescription medication, and many of them take multiple doses per day of several medicines. Medicare Part D, which covers prescription drugs, is a separate entity from Original Medicare (A and B).
Seniors should choose a Part D plan that matches their prescription use. Plans typically have formularies that list the drugs they cover. Furthermore, these drugs are usually ranked in tiers, with higher-tiered medications costing more out-of-pocket. If prescription drug coverage is important to you, make sure it’s included in your Medicare Advantage plan. Otherwise, you’ll need to switch back to Original Medicare and enroll in a separate Part D plan.
Medicare Advantage Resources in Colorado
Even those with a few years of Medicare experience under their belts can be confused by all the choices, and newly eligible seniors are often overwhelmed. Additionally, mistakes during the application process can leave a senior in need of legal representation to ensure coverage. Fortunately, in addition to the federal government’s Medicare website, Colorado provides plenty of free assistance, online and in person, to help individuals navigate the Medicare marketplace.
Colorado’s Area Agencies on Aging
The state has 16 Area Agencies on Aging broken down by regions. These agencies provide aging and disability resources to seniors, including free options counseling and ombudsmen advocacy. Trained professionals not only explain the different Medicare plans, but also assist individuals in completing applications. Region 3A covers the eight counties that include Metro Denver. Services include in-person benefit counseling, help with contacting and enrolling in Medicare plans, and transportation to counseling sessions.
Contact Information: Website | 303-480-6700
Colorado Gerontological Society
This not-for-profit organization provides personalized Medicare help through virtual seminars and in-person meetings. Seniors can call in and talk to trained counselors for assistance with enrollment decisions and any Medicare-related problems. Educational Medicare workshops run weekly, covering a variety of topics. The Society has pharmacy students and insurance company representatives available during virtual and live seminars to help seniors choose the best plan to meet their needs, based on drug use and plan offerings.
Contact Information: Website | 855-293-6911
Colorado Legal Services
Seniors who are having problems receiving their Medicare benefits or payment for claims can receive assistance from Colorado Legal Services. The not-for-profit organization focuses on low-income clients first, but if resources are available will help anyone over 60. In addition to handling disputes over Medicare, Social Security, and Old Age Pension, the law firm assists with completing forms and applications. Seniors can apply for help online or call the location that serves their county.
Contact Information: Website | 303-837-1313
- Sources [-]
https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/special-needs-plans-snp Last accessed April 2021
https://www.medicare.gov/sign-up-change-plans/joining-a-health-or-drug-plan Last accessed April 2021
https://www.kff.org/health-reform/issue-brief/data-note-prescription-drugs-and-older-adults/ Last accessed April 2021
https://www.medicare.gov/ Last accessed April 2021
https://drive.google.com/file/d/0B6jLab7wPqJtTVJSdzljR0Q1anNLd2p1LWRncGtiQ3ZjOG9r/view Last accessed April 2021
Roseann Birch, Medicare Consultant
With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.
Leron Moore, Medicare Consultant
With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.