Medicare Advantage Plans in Florida
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: November 10, 2020
Medicare Advantage, or Medicare Part C, is an alternative to Original Medicare that's made available through private insurance companies under contract with the federal government. Unlike Medicare, which has hospital (Part A) and medical care (Part B) components and offers separate prescription drug plans (Part C), Medicare Advantage can provide all-in-one coverage for these essential healthcare services. By law, Medicare Advantage plans in Florida must provide all of the basic services included in Original Medicare, and many plans have prescription drug coverage as well.
Key Point Module
- 1 In 2019, there were 254 Medicare Advantage plans available in Florida.
- 2 43% of the total Medicare population in Florida is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $11,565 per beneficiary in Florida, which is 15% higher than the national average.
- 4 Available Medicare Advantage plans range from seven to 83 across Florida’s 67 counties.
Medicare Advantage Plans in Florida
Types of Medicare Advantage Plans
There are several types of Medicare Advantage plans in Florida. It’s important to understand the differences between these plans because the type you choose may affect how and where you can receive healthcare services, your monthly premium amount and how much you pay out of pocket each year. Florida’s Medicare Advantage program includes four types of plans: Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-For-Service plans, and Special Needs Plans.
Health Maintenance Organizations (HMO)
Health Maintenance Organizations deliver healthcare services through a network of specific doctors, hospitals, and providers. HMOs usually offer the lowest premiums and out-of-pocket costs of all Medicare Advantage plan types, but they limit costs by only covering in-network care, except for emergency services. If you seek care from an out-of-network doctor or facility, you’ll be responsible for any related costs.
With an HMO, you also need to choose a primary care physician from within the plan’s provider network and get a referral from your PCP if you need to visit a specialist.
Preferred Provider Organizations (PPO)
As with HMOs, Preferred Provider Organizations have a network of plan-approved doctors, healthcare facilities and service providers. Unlike HMOs, PPOs do cover out-of-network care costs but at a lower rate. To pay the lowest co-pays and other out-of-pocket costs, you need to stick with in-network providers.
PPOs don’t make you choose a primary care physician from within the plan’s network or require PCP referrals to see specialists. Although you have fewer restrictions on your healthcare service choices by enrolling in a PPO plan, you can expect to pay higher premiums than with an HMO.
Private Fee-For-Service Plans (PFFS)
Private Fee-For-Service plans offer the most flexibility of all Medicare Advantage plan types. The insurance company that offers a PFFS plan determines the rates paid for covered services. Enrollees can seek care and services from any Medicare-approved doctor or healthcare facility that agrees to their PFFS’s payment terms. Depending on the plan you choose, you may have access to a network of providers that have agreed to treat members at the plan’s rates.
PFFS plans don’t make you choose an in-network primary care physician, and you can visit a specialist without a referral. The greater freedom and choice provided by a PFFS plan comes with higher premiums, copays and coinsurance costs than other types of Medicare Advantage plans.
Special Needs Plans (SNP)
Special Needs Plans restrict enrollment to individuals with certain medical and care needs. An SNP plan might only accept those eligible for both Medicare and Medicaid, people who reside in nursing homes and similar institutions, or individuals with a specific disease or chronic condition, such as diabetes or dementia. SNP plans usually offer benefits and covered services that address the particular needs of its members.
Similar to HMOs, SNPs require that members receive care from a network of approved doctors, hospitals, and other healthcare providers, with the exception of emergency services. Some SNPs require that members choose an in-network primary care doctor or care coordinator, and most require referrals to see specialists. Because of the higher level of targeted healthcare services offered by SNPs, these plans typically have higher premiums and out-of-pocket costs than HMOs, PPOs, and PFFSs.
Enrollment & Eligibility for Medicare Advantage Plans in Florida
To enroll in a Medicare Advantage plan in Florida, you must be a U.S. citizen or legal permanent resident and eligible for or currently enrolled in Medicare Parts A and B. To qualify for Original Medicare enrollment, you must be:
- Aged 65 or older.
- Disabled and receiving Social Security disability benefits (SSDI). Individuals receiving disability insurance must do so for 24 months in order to qualify for Medicare.
- Currently receiving dialysis or be a kidney transplant recipient.
Other eligibility restrictions apply for Medicare Advantage enrollment. You can’t be enrolled in a Medicare supplement insurance plan (Medigap), and you must live in an area of Florida where your chosen Medicare Advantage plan is sold. If you have end-stage renal disease, you may not qualify for most Medicare Advantage plans, except for specific SNPs.
If you meet the eligibility requirements for Medicare Advantage coverage, you must sign up during one of four defined enrollment periods:
- Initial enrollment period: If you become eligible for Original Medicare coverage at age 65, you’re given a seven-month initial enrollment period, which starts three months prior to your birthday month and extends three months beyond. If you qualify for coverage as an SSDI beneficiary, your seven-month period starts three months prior to your 25th month of receiving benefits and continues three months beyond that month.
- Annual open enrollment period: Each year between October 15th and December 7th, Original Medicare beneficiaries may enroll in a Medicare Advantage plan for the first time, and current Medicare Advantage enrollees can switch plans.
- Medicare Advantage open enrollment period: Every year from January 1st to March 31st, current Medicare Advantage members may change plans or switch back to Original Medicare coverage. This period isn’t available to Original Medicare beneficiaries who wish to enroll in Medicare Advantage for the first time.
- Medicare general enrollment period: FromJanuary 1st through March 31st each year, eligible individuals who missed their initial enrollment period can sign up for Original Medicare. Doing so may entitle you to a special enrollment period from April 1st to June 30th, during which you can switch to a Medicare Advantage plan.
- Special Election Periods: Various specific circumstances may allow you to leave an existing MA plan or enroll in a new MA plan.
During the Open Enrollment Period the following can occur:
- Anyone who has (or is signing up for) Medicare Parts A or B can join or drop a Part D prescription drug plan.
- Anyone with Original Medicare (Parts A & B) can switch to a Medicare Advantage plan.
- Anyone with Medicare Advantage can drop it and switch back to just Original Medicare (Parts A & B).
- Anyone with Medicare Advantage can switch to a new Medicare Advantage plan.
- Anyone with a Part D prescription drug plan can switch to a new Part D prescription drug plan.
Prescription Drug Coverage
Medicare prescription drug, or Part D, plans provide cost savings on specific lists of medications known as formularies. These plans are available to anyone eligible for Original Medicare coverage, as well as individuals enrolled in the Medicare Advantage program. The availability of Part D coverage differs according to the type of Medicare Advantage plan you choose. PFFS plans typically include coverage for prescription drugs, and those that don’t, allow enrollees to sign up for a separate Part D plan. SNP plans have to include prescription coverage by law. Many HMO and PPO plans include Part D coverage. However, if you choose one of these plans that lacks prescription drug coverage, you can’t enroll in a stand-alone Part D plan. By doing so, you’d be switched back to Original Medicare and lose your Medicare Advantage plan.
Medicare Advantage Resources in Florida
The various types and sheer number of Medicare Advantage plans in Florida can make choosing the right one a confusing and overwhelming task. When comparing plans and coverage options, it’s essential to weigh important factors, including premiums, out-of-pocket costs, covered benefits, and provider network limitations. There are free resources available throughout the state where you can get unbiased information, answers to questions, and guidance about the Medicare Advantage program and the plans available in your area.
Florida Senior Legal Helpline
The Florida Senior Legal Helpline offers assistance with issues related to Medicare Advantage coverage and other civil legal matters. Low-income residents aged 60 and older can call the helpline to schedule a free telephone consultation with a paralegal or attorney. If additional assistance is needed, help is provided with finding legal representation in a caller’s local area. The helpline is staffed on weekdays during regular business hours.
Contact Information: Website | (888) 895-7873
The Florida Department of Elder Affairs administers the statewide Serving Health Insurance Needs of Elders (SHINE) program to help Medicare-eligible individuals understand their healthcare options and make informed coverage choices. Trained SHINE counselors can provide unbiased information regarding Medicare, Medicare Advantage, and prescription drug coverage, as well as the eligibility and enrollment requirements for each Medicare program. SHINE hosts informational events in communities across the state, and one-on-one counseling is offered by phone and at designated sites in each country. Seniors can visit the SHINE website to learn about upcoming community events and counseling sites in their area.
Contact Information: Website | (800) 963-5337
Florida Area Agencies on Aging
The 11 Area Agency on Aging (AAA) offices located across Florida help seniors aged 60 and older, disabled adults, and their families access beneficial local, state and federal resources. One of the many valuable services AAAs offer is free, confidential Medicare counseling to help beneficiaries and eligible individuals make informed healthcare coverage choices. Trained AAA staff can provide personalized guidance about Original Medicare, Medicare Advantage, Medigap, and Part D prescription drug plans, information about eligibility and enrollment requirements, and advice about available programs that may reduce premiums and out-of-pocket costs. The Florida Department of Elder Affairs oversees AAAs, and you can visit the DEA’s website to find the location and contact details of the agency serving your area.
Contact Information: Website | (800) 963-5337
- Sources [-]
https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/special-needs-plans-snp Last accessed April 2021
https://www.hhs.gov/answers/medicare-and-medicaid/who-is-elibible-for-medicare/index.html Last accessed April 2021
https://www.medicare.gov/manage-your-health/i-have-end-stage-renal-disease-esrd Last accessed April 2021
https://www.medicare.gov/sign-up-change-plans/joining-a-health-or-drug-plan Last accessed April 2021
https://www.medicare.gov/Pubs/pdf/11135-prescription-drug-coverage-with-ma-mcp.pdf 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.