Medicare Advantage Plans in Kentucky
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: March 17, 2021
Medicare Advantage, also known as Medicare Part C, is available to Kentucky seniors who are already enrolled in Original Medicare Parts A and B. Medicare Advantage provides all of the hospital and medical coverage that's standard with Parts A and B, but also typically covers the cost of prescription drugs, vision, dental, and hearing services. Unlike other Medicare plans managed by the federal government, Medicare Part C is handled by private insurance companies approved by Medicare.
- 1 In 2019, there were 53 Medicare Advantage plans available in Kentucky.
- 2 29% of the total Medicare population in Kentucky is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $10,096 per beneficiary in Kentucky, which is the same as the national average.
- 4 Available Medicare Advantage plans range from 10 to 35 across Kentucky’s 120 counties.
Kentucky’s Medicare Advantage plans can vary significantly in coverage and costs. By considering the costs and coverage of available plans, seniors can choose one that best suits their budget and individual needs. The availability of Medicare plans also depends on the participant’s geographic location and the individual health insurance provider. All plans must adhere to Medicare’s terms of coverage and provide the same benefits, rights and protection as Original Medicare. The types of Medicare Advantage plans available include Health Maintenance Organizations (HMO), Preferred Provider Organizations (PMO), Private Fee-For-Service plans (PFFS), and Special Needs Plans (SNP).
Medicare Advantage Plans in Kentucky
Types of Medicare Advantage Plans
The Medicare Advantage program in Kentucky offers seniors a range of plan types, but the availability of specific plans vary across the state. Standard options include HMOs, PPOs, and PFFSs. For seniors in need of specialist treatment due to a specific illness or condition, an SNP may be the most suitable option. Each plan has its own eligibility criteria and understanding these rules can be a little confusing. The good news is that there are a number of free and unbiased counseling services available that can help Kentucky seniors make the right decision.
Health Maintenance Organization (HMO)
When a participant enrolls in an HMO plan, all medical care and treatment must be administered by a specific network of providers. The exception to this rule is if the participant requires emergency medical treatment. If general medical treatment is sought beyond this network, the participant must meet all subsequent costs. The participant is also responsible for selecting an in-network primary care physician who makes all treatment decisions and specialist referrals if necessary. An HMO plan may be one of the most restrictive Medicare Advantage choices in Kentucky when it comes to network rules, but these restrictions make it one of the most affordable. An HMO plan also comes with low or no deductibles.
Planned Provider Organizations (PPO)
PPO plans usually cost more than HMO plans, and they always include deductibles. However, these plans offer participants more flexibility when it comes to network rules. While PPO plans have a network of healthcare providers, the network is more extensive. This gives seniors more choice when selecting a provider. With a PPO plan, participants are also covered for at least part of the cost of any medical services they receive from out-of-network providers. However, it’s important to note that in-network providers offer reduced rates to PPO participants, so enrollees pay lower co-pay and coinsurance costs. PPO plan participants aren’t required to choose a primary care provider and don’t need a referral to see a specialist.
Private Fee-For-Service Plans (PFFS)
PFFS plans are ideal for seniors looking for maximum flexibility from their healthcare plan. PFFS plans may have a full or partial network of healthcare providers, and some don’t have a network at all. When enrolled in this type of coverage, participants have the freedom to receive care from any hospital, doctor or other provider. The only caveat is that these providers must accept the terms of the plan. The benefit to participants that stay within their plan’s network is that their costs will be lower. On a PFFS plan, healthcare provider payments are made on a fee-for-service basis. The healthcare provider determines how much members pay for each service and how much a plan pays. As a result, PFFS plans can come with a higher premium.
Special Needs Plans (SNP)
SNP plans are only available to certain Medicare participants and have stricter enrollment requirements. SNP plans usually have higher premiums than other Medicare Advantage plans. However, these higher costs are offset by the additional range of tailored benefits they offer to members. For example, under an SNP plan, seniors may be eligible for coverage if they have certain chronic or disabling diseases or illnesses. SNPs also come with a very targeted network of providers, and participants must receive all treatment and care from within this network. Another point to note is that it may be challenging for seniors to find an SNP plan in their area due to the limited geographic coverage of these plans.
Enrollment & Eligibility for Medicare Advantage Plans in Kentucky
Kentucky seniors who are eligible for Medicare Parts A and B can also enroll in Kentucky’s Medicare Advantage program if they satisfy the following criteria:
- Are 65 years or older, or if younger, have a qualifying disability
- Live in a region where Medicare Advantage plans are available
- Not enrolled in a Medigap plan
- Be a U.S. citizen or permanent resident
- Not have End-Stage Renal Disease — an SNP plan may be an option
Enrollment periods for Medicare plans run throughout the year and are subject to different rules and conditions. Some periods are only available to first-time applicants, while others can only be accessed by existing members looking to move to another Medicare plan. Current Medicare enrollment periods are as follows:
- Initial coverage periods for Medicare Advantage are available to seniors applying for a plan for the first time. The time frame for enrollment is seven months, which includes the three months before the applicant’s 65th birthday month and the three months that follow.
- Annual election periods are available to existing Medicare Advantage participants who want to switch plans and Original Medicare beneficiaries changing to Medicare Advantage for the first time. Enrollment starts on October 15th and ends on December 7th.
- Medicare Advantage open enrollment periods are only available to existing Medicare Advantage members who are switching back to Original Medicare or changing plans. Enrollment starts on January 1st and ends on March 31st.
- Special enrollment periods are available to participants of Medicare Part A who enrolled in Part B during the open enrollment period from January 1st to March 31st and want to make the switch to Medicare Advantage. These enrollment periods run from April 1st to June 30th.
Prescription Drug Coverage
Prescription drug coverage, also known as Medicare Part D, is an optional plan available to all Original Medicare members. Many Medicare Advantage plans include prescription drug coverage and are known as MA-PD plans. HMO and PPO plan members whose plan doesn’t include prescription drug coverage aren’t eligible for a standalone Medicare Part D plan. Some PFFS plans include prescription drug coverage, and if not, participants can enroll in a standalone Medicare Part D plan. It is a legal requirement that SNP plans include prescription drug coverage.
Medicare Advantage Resources in Kentucky
It’s essential that seniors in Kentucky have access to the highest level of care and healthcare plans that align with their individual needs. Kentucky’s Medicare Advantage program provides seniors with an impressive selection of health insurance plans. However, the wide range of choices can also lead to confusion, especially where eligibility criteria and benefits are concerned. Fortunately, help is on hand from a number of Kentucky resources that have been set up to provide seniors with free and unbiased advice.
State Health Insurance Assistance Program (SHIP)
Kentucky’s State Health Insurance Assistance Program (SHIP) provides counseling, information and advice to seniors, their families, and caregivers to help them choose the most suitable Medicare plan. This service is managed in conjunction with the Department for Public Health Kentucky Prescription Assistance Program (KPAP) and is provided at no charge to Kentucky seniors. From answering questions about benefits, claims, and supplementary policies to advising on how to access Medicare at a reduced cost, SHIP counselors are trained in all areas of Medicare and health insurance in general.
Contact Information: Website | 877 293-7447
Kentucky Senior Medicare Patrol
The Kentucky Senior Medicare Patrol (SMP) is a group of highly trained and experienced volunteers who offer support to Medicare beneficiaries, their families, and caregivers and help them understand the Medicare program and how they can avoid healthcare scams, fraud, and errors. The organization also runs periodic public events that provide seniors with information about Medicare changes or updates.
Contact Information: Website | 877-603-6558
Kentucky Legal Aid
The Kentucky Legal Aid law firm helps Medicare and Medicaid enrollees appeal denied coverage and resolve claim issues. Other services include Power of Attorney documents and long-term care advocacy. All questions and queries are answered free of charge by trained and experienced counselors. The nonprofit organization focuses on low-income clients.
Contact Information: Website | 800-782-1924
- 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
https://www.medicare.gov/drug-coverage-part-d Last accessed April 2021
https://chfs.ky.gov/agencies/dail/Pages/ship.aspx Last accessed April 2021
https://louisvilleky.gov/government/health-wellness/senior-medicare-patrol Last accessed April 2021
https://www.klaid.org/what-we-do 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.