Medicare Advantage Plans in Delaware
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Updated: Jul 06, 2021
Many seniors or disabled individuals may decide to select their healthcare through Medicare Advantage (or Part C of Medicare). Essentially this is Medicare coverage handled by a private healthcare company. All companies that provide Medicare Advantage plans are legally required to provide the same benefits individuals would receive under Part A and Part B of Original Medicare. The difference is that some of these Medicare Advantage plans offer additional benefits, such as vision, health, and dental, although at an added cost. Many of these plans also include prescription drug coverage, but not all of them.
- 1 In 2019, there were 10 Medicare Advantage plans available in Delaware.
- 2 13% of the total Medicare population in Delaware is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $9,823 per beneficiary in Delaware, which is 3% lower than the national average.
- 4 Available Medicare Advantage plans range from 17 to 19 across Delaware’s three counties.
When Delaware Medicare beneficiaries choose a Medicare Advantage plan, they can select one of four different plans. These plans may be similar to what they had when they were working and receiving employer-sponsored health care. Some of these plans require in-network medical providers, while others are less restrictive but at an added cost. Most of these plans provide for medication coverage, but some do not.
During the open Medicare Advantage enrollment periods, Delaware residents who select a Medicare Advantage plan may also move to another Medicare Advantage plan if they are not happy with their current plan or back to Original Medicare.
Medicare Advantage Plans in Delaware
Types Of Medicare Advantage Plans
Before selecting one of the four types of Medicare Advantage plans, it’s important to ask some key questions:
- How much of a premium do I want to pay?
- Am I happy with only using in-network resources, or would I like to be able to see out-of-network providers, especially if I plan to travel?
- Do I want a plan that provides Medicare Part D coverage?
Here’s something that all seniors who wish to take advantage of Delaware’s Medicare Advantage program should know – the selection is limited to plans available in your county. So, if you live in New Castle County, you cannot enroll in a plan that’s sold only in Kent County.
Health Maintenance Organizations (HMOs)
As with non-Medicare related HMOs, these plans require members to use in-network healthcare providers. They must also select a primary care physician, and referrals are needed before they see a specialist. The limitations, however, do not apply to emergencies, out-of-network urgent care or out-of-network dialysis. Medicare Advantage HMO plans are a popular choice in Delaware since many of these plans are inexpensive or don’t require a premium. Additional benefits like vision, dental, and hearing are available at an extra cost. Seniors should opt for a plan that includes prescription drug coverage if they take a lot of medication. HMO plans still require members to pay Original Medicare’s Part B premium and if applicable, the Part A premium.
Preferred Provider Organizations (PPOs)
Members in Medicare Advantage PPO plans don’t need to use in-network healthcare providers, although there is an added cost to use out-of-network services. Medicare Advantage PPO members also don’t need to name a primary care physician, nor do they need a referral to see most specialists, although visiting an in-network specialist will always be less expensive. As with HMO plans, additional benefits are available at an added cost. Most of these plans also provide Medicare prescription drug coverage.
Private Fee-For-Service Plans (PFFS)
These Medicare Advantage plans give its members more flexibility in selecting a healthcare provider, but there are some restrictions. PFFS plans normally contract with a healthcare network that will provide service to the plan’s members. Members may use out-of-network services, provided that the doctors, specialists, or hospitals accept the payment terms of the member’s PFFS plan. However, if there is an emergency or a member requires out-of-network urgent care or out-of-network dialysis, all PFFS plans must provide service. Members of a Medicare Advantage PFFS plan do not need to select a primary care physician or obtain referrals for specialists in most cases. Most plans provide drug coverage, but some do not.
Special Needs Plans (SNP)
Medicare Advantage SNPs are designed to help people with specific healthcare challenges such as ESRD or reside in a skilled nursing facility. All SNPs are connected to specialists who treat the kind of medical conditions that affect their members. Members of the plan need to use in-house healthcare providers and must select a primary care physician and obtain referrals to see most specialists. Again, exceptions are made for emergencies, out-of-network urgent care, and out of network dialysis for those dealing with ESRD. All SNPs are required by law to provide prescription drug coverage.
Enrollment and Eligibility for Medicare Advantage Plans in Delaware
Eligibility requirements and specific enrollment periods exist for all individuals interested in selecting a Medicare Advantage plan.
Eligibility criteria include:
- An individual must be at least 65 years of age or receiving a Social Security disability benefit or have ALS or ESRD
- A senior must be a US citizen or have been a permanent resident of the United States for at least five years
- They must have worked long enough to be eligible for Social Security
- The senior must live in the county where their preferred Medicare Advantage plan is available
- They must be enrolled in Medicare’s Part A and Part B
The specific enrollment times for Medicare Advantage plan are:
- Initial enrollment occurs three months before an individual’s 65th birthday, the month of the birthday, and the three months following the birthday.
- During the yearly Medicare annual enrollment period, which lasts from October 15 to December 7, seniors can move from Original Medicare to a Medicare Advantage plan. If they’re on a Medicare Advantage plan, they can return to Original Medicare. They may also switch between Medicare Advantage plans.
- Open enrollment for Medicare Advantage runs from January 1 to March 31. During this period, a member of one Medicare Advantage plan can switch to another Medicare Advantage plan or return to Original Medicare
- The last enrollment period is general enrollment, which runs from April 1 to June 30, and it only applies to certain applicants. Seniors who recently enrolled in Medicare’s part B plan can now select a Medicare Advantage plan
Prescription Drug Coverage
Prescription drug coverage under Medicare Advantage plans may differ from plan to plan:
- Most PPOs and HMOs provide prescription drug coverage. In some cases, they will require separate premiums
- If you select a Medicare Advantage HMO or PPO which does not include prescription drug coverage, you may not join a Medicare Part D plan to provide that coverage. If you do, your Medicare Advantage plan will end, and you will be returned to Original Medicare
- If you have selected a PFFS plan that does not provide prescription drug coverage, you may enroll in a separate Medicare Part D plan
- SNPs are legally required to provide prescription drug coverage
Medicare Advantage Resources in Delaware
For seniors about to turn 65 or anyone else who becomes eligible for Medicare or a Medicare Advantage plan, determining these plans’ benefits can be a bit confusing. Deciding whether to stay on Original Medicare or select Medicare Advantage can often depend upon outside factors like income, if you like the county’s plans where you live, or if you have a spouse who is still working through whom you get healthcare coverage.
Friends and family can provide some help, but even they may be confused by all the various options. Fortunately, resources do exist in Delaware to help seniors navigate their way through all the information to find a plan that suits them best.
Delaware Medical Assistance Bureau
As a part of the Delaware Department of Insurance, this agency provides free healthcare insurance counseling for seniors or their families. They offer help with Medicare, Medicare Advantage, Medigap and other long-term healthcare insurance programs, all at no cost. Seniors can set up an appointment over the phone or in-person.
Contact information: Website | 302-674-7364
Delaware Prescription Assistance Program
This assistance program is aimed at seniors who are at least 65 or individuals receiving Social Security disability benefits currently residing in the state. Their income must be at or below 200% of the federal poverty level, or if their income is above that level, they must be able to show that their drug costs are 40% or more of their income. It provides each eligible individual up to $2500 in assistance for each calendar year. The program covers medically necessary prescription drugs.
Contact information: Website | 800-996-9969
Delaware Aging and Disability Resource Center (ADRC)
The ADRC provides Delaware seniors with healthcare advice on topics like Medicare or Medicare Advantage, transportation, housing, and other aging issues. The website also provides a guide, which anyone can download, explaining what services are available in the state. Seniors can also call the ADRC assistance line and request more information.
Contact information: Website | 800-223-9074
- Sources [-]
https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/special-needs-plans-snp | Last accessed June 2021
https://insurance.delaware.gov/divisions/dmab/ | Last accessed June 2021
https://www.dhss.delaware.gov/dhss/dmma/dpap.html | Last accessed June 2021
http://www.delawareadrc.com/ | Last accessed June 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.