Medicare Advantage Plans in Georgia
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: October 16, 2020
Medicare consists of Parts A, B, C, and D. Parts A and B combined are referred to as Original Medicare, which includes hospitalization and general healthcare coverage. Part C refers to Medicare Advantage plans, which replace Parts A and B with bundled coverage that often has extra benefits, such as vision, dental, and possibly prescription drug coverage. Part D is the stand-alone prescription coverage offered by Medicare. Georgia seniors who opt for a Medicare Advantage plan get similar levels of care to what's provided through Original Medicare, but the plans are administered through a third-party insurance company. While Medicare premiums are set by the federal government, out-of-pocket costs vary for each Medicare Advantage Plan.
- 1 In 2019, there were 63 Medicare Advantage plans available in Georgia.
- 2 35% of the total Medicare population in Georgia is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $10,328 per beneficiary in Georgia, which is 2% higher than the national average.
- 4 Available Medicare Advantage plans range from eight to 61 across Georgia’s 159 counties.
Throughout Georgia, there are 63 Medicare Advantage plans available, but they’re offered at the local level, so not all counties have the same plans available.
Medicare Advantage Plans in Georgia
Types of Medicare Advantage Plans
In Georgia, there are four types of Medicare Advantage plans, with HMOs and PPOs being the most commonly available. PFFS plans are offered in a few Georgia counties, so this option may not be available in your area. SNPs serve Georgia residents throughout the state, but enrollment is limited by strict eligibility criteria.
Health Maintenance Organizations (HMO)
HMOs are some of the most common Medicare Advantage plans, in part due to their affordability. These plans work by providing a network of healthcare professionals who handle all aspects of your care. You’re required to use in-network care providers or pay the cost out-of-pocket with a few exceptions, such as emergency and urgent care situations. You must select a primary care doctor when enrolled in an HMO and obtain all specialist referrals through that doctor. HMOs tend to be the most restrictive type of Medicare Advantage plan, but they usually cost less.
Preferred Provider Organizations (PPO)
PPO plans work with a network of healthcare professionals to offer comprehensive care. They operate similarly to HMOs, but with more flexibility. In a PPO, you can select in- or out-of-network doctors and hospitals, and the insurance will cover either. (Note: Providers are not obligated to accept PPO plans. Check each provider before scheduling services.) However, costs are generally higher for out-of-network services. PPO networks are often larger than HMO networks, and there’s no need to select a primary care doctor or obtain referrals before making appointments with specialists.
Private Fee-For-Service Plans (PFFS)
PFFS plans operate differently than PPOs and HMOs. The insurance company sets a reimbursement rate for services and a share of the cost for members. When enrolled in this type of plan, you can go to any healthcare provider who accepts the payment terms for your plan. Some PFFS plans offer a provider network with service guarantees, and healthcare providers outside that network may not agree to the terms or be willing to treat you, except in an emergency situation. And be aware that a doctor or hospital may stop taking your insurance at any time, with little notice.
Special Needs Plans (SNP)
SNPs offer benefits and services tailored to enrollees with specific care needs, conditions or illnesses. SNPs may accept individuals living in a nursing home or who require a nursing home level of care, eligible for both Medicare and Medicaid, or diagnosed with a disabling disease or illness. As a member, you need to seek care from in-network providers, except in emergencies. Because they provide targeted services and coverage, SNPs often have higher premiums and out-of-pocket costs than other types of Medicare Advantage plans.
Enrollment & Eligibility for Medicare Advantage Plans in Georgia
The year you turn 65 years old, you become eligible to enroll in Medicare. While enrollment is not mandatory, waiting to enroll may come with financial penalties if you join after the initial enrollment period. If you’re already receiving Social Security benefits when you turn 65, enrollment in Medicare Parts A and B is automatic. If you’re eligible for Original Medicare, you also have the option to enroll in a Medicare Advantage plan. To do so, you must:
- Live in an area where a plan is available
- Not have Medigap insurance
- Be a U.S. citizen or legal permanent resident
SNPs are the only plans that accept those with end-stage renal failure, and dialysis treatments are covered out-of-network when not available in-network.
Also, some individuals are eligible for Medicare under the age of 65 if they’ve been receiving disability benefits for at least 24 months.
There are no general dates for initial Medicare enrollment. Instead, you become eligible to enroll three months before your birthday month, during your birthday month and for up to three months after, giving you a seven-month period to explore your options the year you turn 65. After your initial enrollment period, there are yearly time frames during which you can make changes or enroll in a Medicare Advantage plan:
- During the annual election period from October 15th through December 7th, Original Medicare members can change to a Medicare Advantage plan, and those already enrolled in Part C can change plans.
- During the open enrollment period from January 1st through March 31st, those currently enrolled in Medicare Advantage can switch plans or back to Original Medicare.
- Those who sign up for Medicare Part B during the general enrollment period from January 1st to March 31st may be able to switch to a Medicare Advantage plan during a special enrollment period from April 1st through June 30th.
Prescription Drug Coverage
Prescription drug coverage is handled separately through Original Medicare. Original Medicare offers no drug coverage, but seniors with Parts A and B may also enroll in a stand-alone Part D plan. Many Medicare Advantage plans include drug coverage, though some plans may charge a separate premium for prescription benefits. When enrolling in a Medicare Advantage plan, remember that you may not be eligible for Part D with your plan. If you don’t have prescription coverage and need it, you will need to select an alternative Advantage plan that offers it or revert to Original Medicare. All SNPs include prescription coverage.
Medicare Advantage Resources in North Carolina
After retirement, most seniors do not have employer-sponsored health insurance, making Medicare sign-up a priority. Medicare Advantage plans often offer more coverage than Original Medicare, including benefits such as hearing, vision, and dental. With 63 Medicare Advantage plans available throughout the state, and at least 8 in every county, it can be difficult to make a final decision about insurance. Comparing the various plans to find one that offers the right scope of coverage at an affordable price with reasonable out-of-pocket expenses can be confusing and time-consuming. Fortunately, there are resources available to help Medicare-eligible seniors learn about their options so they can decide on the best Medicare Advantage plan for their needs.
GeorgiaCares is the State Health Insurance Assistance Program (SHIP), and it is administered by the Georgia Department of Human Services Division of Aging Services. It offers free, factual information about Original Medicare, Medigap, Medicare Advantage, and prescription drug coverage options. The goal of the services offered through this program is to help seniors and their caregivers make informed decisions about insurance and to better understand Medicare benefits. After you select a plan, counselors can help with enrollment and understanding your benefits in action.
Contact Information: Website | 866-552-4464
Consumer Services Division
The Office of Insurance and Safety Fire Commissioner operates the Consumer Services Division to provide Georgia residents with accurate health insurance information and complaint resolution. The online complaint portal allows seniors to explain problems and ask for resolution assistance from a regulatory agency. Some issues that might occur include billing errors, Medicare fraud or waste, and policy cancellations. If an insurance company denies a covered service, that might be reason enough to file a complaint. The Consumer Services Division works with healthcare providers, insurance companies, and consumers throughout Georgia.
Contact Information: Website | 404-656-2070
empowerline, formerly known as the AgeWise Connection, is a nonprofit organization serving the Atlanta Metro area and is one of several Area Agencies on Aging across the state. Trained agency staff is available to provide counseling to help seniors better understand their Medicare and Medicare Advantage coverage options. Assistance applying for Medicaid is also offered for those who meet the eligibility requirements. In addition to health insurance information, the agency also acts as an assistance portal for a variety of community supports for seniors, including home-delivered meals, locating ADA-compliant housing, finding help for around the house, as well as an array of other aging-related services.
Contact Information: Website | 404-463-3333
- Sources [-]
https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans Last accessed April 2021
https://www.medicare.gov/blog/medicare-enrollment-period-2020 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.