Medicare Advantage Plans in Maryland
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: October 16, 2020
Medicare Advantage Plans (Part C) are an alternative to Original Medicare (Parts A and B) and typically provide more options. Private insurance companies contract with Medicare to offer the same coverage and most also include prescription drug plans, replacing Part D. The cost of premiums for Advantage Plans are often higher than Original Medicare. Still, the expanded coverage may be worth the extra costs upfront. Parts A and B include hospital insurance and health care only while Part C plans may also have some vision and dental coverage or long-term care insurance.
- 1 In 2019, there were 26 Medicare Advantage plans available in Maryland.
- 2 11% of the total Medicare population in Maryland is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $10,115 per beneficiary in Maryland, which is on par with the national average of $10,096.
- 4 Available Medicare Advantage plans range from 1 to 24 across Maryland’s 24 counties.
Navigating Medicare options can be complex. Medicare Advantage plans include a variety of different options and coverage levels. Your location determines what Medicare Advantage plans are available to you. Some insurance providers may not serve all areas and may offer limited plan selection. If you had health insurance through your employer, these options might sound familiar. Assess each plan based on what it provides and the provider network in your area. What you need in the way of healthcare coverage will determine which Advantage plan is right for you.
Medicare Advantage Plans in Maryland
Types of Medicare Advantage Plans
In Maryland, there are four types of Medicare Advantage plans. Maryland’s Medicare Advantage program includes options with and without drug coverage, along with opportunities to take advantage of low-cost premiums in exchange for higher deductibles. Here is a quick overview of the four options for Maryland residents.
Health Maintenance Organizations (HMO)
Health Maintenance Organizations, more commonly referred to as HMOs, provide a network of doctors and other healthcare providers that you can use. Within a network, most services are provided according to a predetermined fee schedule, and you may owe a copay at the time of service. Out-of-network for services usually requires pre-authorization, and you may need a referral to see a specialist. You may also have a deductible to meet before your Advantage plan starts to pay for services. Most HMOs include prescription drug coverage, but those that don’t may also impact your ability to enroll in Medicare Part D.
Coverage for emergency services, urgent care, and dialysis are benefits that are typically out-of-network.
Preferred Provider Organizations (PPO)
Similar to an HMO, a PPO plan offers discounted rates for healthcare services in-network. Unlike an HMO, you can opt to go out-of-network for services and pay a higher — but still covered by insurance— rate. For example, services that bill you 20% for in-network service might bill you 40% if you choose an out-of-network provider. That said, out-of-network providers are not obligated to accept PPO plans.
The flexibility to choose which doctors you use and which hospitals is part of the appeal with a PPO. You don’t need to select a primary care doctor, and you likely won’t need referrals to see a specialist.
Private Fee-For-Service Plans (PFFS)
With a PFFS option, you can go anywhere that accepts the payment terms for your plan. You pay the pre-negotiated rate for all covered services. Not all providers accept this type of health insurance. Providers may opt out at any time, except for in-network doctors who have an agreement with the insurance company to see patients with this plan. While prescription drug coverage is often included, you can opt to enroll in Part D when it is not.
Special Needs Plans (SNP)
Special Needs Plans offer targeted coverage for those who have specific, chronic diseases. To meet the needs of these patients, this type of insurance might have a formulary of covered services and prescriptions tailored to the specific illness, such as heart disease. Those enrolled must opt for in-network care when it is available, but an SNP does allow out-of-network options for those with end-stage renal disease patients who need dialysis. Prescription drug coverage is always included with an SNP. In most cases, you will need to select a primary care doctor and ask for referrals to access any needed specialist care.
Enrollment & Eligibility for Medicare Advantage Plans in Maryland
To enroll in a Medicare Advantage Plan in Maryland, you must meet specific criteria. First, you must be enrolled in both Medicare Parts A and B to qualify for an Advantage plan. Medicare enrollment starts at age 65. For seniors who are still working and on their employer’s health insurance policy, enrollment can be delayed. You can keep your employer-sponsored health insurance (and their contributions to premium payments) until you retire. Individuals who have been receiving disability benefits for at least 24 months are also eligible for Original Medicare.
If you start collecting Social Security at age 65, Medicare enrollment may be automatic, but if it’s not, be sure to enroll in both Part A and Part B to avoid any penalties or coverage lapses. If you are opting for an Advantage Plan, you may need to apply during your original enrollment period or wait for open enrollment.
Enrollment for Medicare starts three months before your 65th birthday month and extends for three months after, creating a 7-month window in which you can enroll. If you opt to enroll in a Medicare Advantage Plan, annual open enrollment runs from January 1st through March 31st of each year. If you are currently enrolled in Original Medicare, you can switch to an Advantage Plan during the open enrollment for this program, which runs from October 15th to December 7th, annually.
Be aware that you can’t enroll in a Medicare Advantage plan if you have Medigap or end-stage renal disease. For patients with end-stage renal disease, a special needs plan may be an option.
Prescription Drug Coverage
Prescription drugs are often billed separately from your health or hospitalization coverage. Medicare offers coverage for prescriptions through its Part D plan, but enrollment in Part D can impact your Medicare Advantage enrollment. Many Medicare Advantage plans include prescription drug coverage, but there are exceptions. When a Medicare Advantage plan doesn’t cover prescriptions, opting in to Part D can automatically drop you from your Advantage plan and drop you back onto Original Medicare. If you are enrolled in an MSA or a PFFS plan, you may be eligible for dual enrollment in Part D and your chosen Advantage plan.
Medicare Advantage Resources in Maryland
Medicare coverage is complex, and after retirement, you may not have much flexibility in your finances to cover an unexpected health emergency. Finding the right combination of plans is important to ensure you can live out your retirement in comfort and security. Get help when comparing different plans and coverage options to better understand what your out-of-pocket expenses might look like under a Medicare Advantage plan. Original Medicare may not cover long-term care, vision, dental, or other ancillary services. Below are some resources to help you better understand the options and make informed healthcare decisions.
Maryland Health Care Commission
The Maryland Health Care Commission offers a quick guide to the different types of Medicare plans and directions to download a coverage calculator. With the calculator, you can quickly determine what services Medicare pays for and what you might be billed for out-of-pocket. It also links to other informational resources, including the annual handbook published by the federal government, Medicare & You. The site also provides access to a list of possible service providers, such as nursing homes, assisted living communities, and adult day care.
Contact Information: Website | 410-764-3460
State Health Insurance Assistance Program (SHIP)
Montgomery County offers the SHIP program in partnership with the Jewish Council for the Aging of Greater Washington. County residents can get help in making healthcare coverage decisions and information about Medicare, Medigap, Advantage plans, prescription drug plans, employer insurance plans, and long-term care insurance. Individual counseling is available to discuss your specific situation and coverage needs. Easy-to-understand comparison charts and tables provide a visual look at potential plans, their coverage levels, and how much a senior might expect to pay out-of-pocket. One-on-one counseling is provided over the phone, and most residents get a call back within 48 hours. In-person assistance is also available.
Contact Information: Website | 301-255-4250
Maryland Senior Medicare Patrol
The Maryland SMP (Senior Medicare Patrol) is an initiative that is designed to help prevent Medicare fraud. It provides Maryland residents with free, confidential assistance in identifying and reporting healthcare fraud, waste, or errors, helping ensure seniors receive the highest quality care without excess costs. Home counseling visits are available for seniors who do not travel. Some examples of common types of fraud/error might include gifts when using a particular doctor or health plan, misleading claims about insurance coverage, or delivering substandard care. Seniors might also report instances where their insurance coverage is stopped without reasonable cause or required notification.
Contact Information: Website | 410-767-1100
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.