Medicare Advantage Plans in Massachusetts
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: February 3, 2021
Once a senior or a disabled person who receives Social Security benefits becomes eligible for Medicare, they may also choose to enroll in a Medicare Advantage Plan in Massachusetts. Private health insurance companies offer these plans, and they cover Original Medicare Part A and Part B benefits. (Medicare Advantage is known as Medicare Part C).
These companies are required by law to provide the same benefits recipients would receive under Original Medicare, but some plans offer additional perks like vision, dental, and hearing. Many Medicare Advantage companies in Massachusetts also cover prescription drug costs, but not all. Your out-of-pocket costs depend on which plan you choose and whether it has a high or low deductible.
- 1 In 2019, there were 57 Medicare Advantage plans available in Massachusetts.
- 2 21% of the total Medicare population in Massachusetts is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $10,015 per beneficiary in Massachusetts, which is 1% lower than the national average.
- 4 Available Medicare Advantage plans range from 1 to 45 across Massachusetts’s 14 counties.
The decision about whether to enroll in a Medicare Advantage Plan in Massachusetts rests with each Medicare recipient. They can choose to remain with Original Medicare or enroll in a Medicare Advantage Plan during specific enrollment periods. Original Medicare recipients who wish to switch to a Medicare Advantage Plan in Massachusetts may choose from four different kinds of plans.
Some of these plans will be familiar to anyone who has ever received their healthcare insurance through an employer. Some require you to have a primary care physician and to seek referrals while other plans require that you use only their in-network doctors and hospitals. Some of these plans provide Medicare prescription drug coverage while others do not.
Medicare Advantage Plans in Massachusetts
Types of Medicare Advantage Plans
When a Medicare beneficiary considers switching to a Medicare Advantage Plan in Massachusetts, they need to ask themselves several important questions, such as:
- Do I want a plan that includes prescription drug coverage?
- Do I want a plan that has a low premium but may provide fewer additional benefits (for instance, in Massachusetts, the average premium is $28 a month, but some plans have $0 premiums while others have premiums in the hundreds of dollars)?
- Do I only want to use in-network doctors or to have the option of going out-of-network?
Depending upon which county you live in, there can be various Medicare Advantage Plans in each of the four plan types from which to choose.
Health Maintenance Organizations (HMO)
All Medicare Advantage HMO plans in Massachusetts require participants to select doctors, specialists, and hospitals from the HMO’s network. Referrals are required to see specialists. An exception to the in-network requirement is the need for emergency care or out-of-area urgent care. Most of these types of Medicare Advantage Plans offer prescription drug coverage, but not all of them.
Many HMOs offer Massachusetts Medicare beneficiaries low costs and often don’t require a premium. Seniors who choose an HMO plan still need to pay the Original Medicare Plan B Premium and, if applicable, the Part A premium.
Preferred Provider Organizations
PPO Medicare Advantage Plans in Massachusetts also feature an in-network group of healthcare providers and hospitals from which recipients can choose. Unlike an HMO plan, you can choose to work with a doctor from outside the network. The PPO will only cover a certain amount, however, when you use an out-of-network provider.
Medicare Advantage PPO plans in Massachusetts don’t require you to name a primary care physician, nor in most cases do they need the member to get a referral to see a specialist. Once again, the PPO plan may offer more benefits than Original Medicare, but there is an added cost. Most PPO plans also offer Medicare prescription drug care.
Private Fee-for-Service Plans (PFFS)
Medicare Advantage PFFS plans are flexible in terms of the healthcare provider you choose. These plans set limits on what they will pay physicians and hospitals. They also determine what costs you will pay for the services you receive.
In some cases, a PFFS will contract with a network of healthcare providers who will see the members of a PFFS plan. In other cases, a plan participant may see a healthcare provider in any PFFS plan, but some of these doctors, specialists, and hospitals will not accept what the plan will pay and may deny coverage. An exception is made for emergencies when all doctors and hospitals must treat plan participants.
Prescription drug costs are covered in some PFFS plans. If the plan does not cover drugs, however, plan members can join a separate Medicare prescription drug plan.
Special Needs Plans (SNP)
Only Medicare beneficiaries who have specific conditions or diseases, like End-Stage Renal Disease (ESRD), can select an SNP plan. These plans are tailored to provide coverage for the particular healthcare needs of the Medicare beneficiaries who join them.
Plan participants must work with the plan’s network of doctors, specialists, and hospitals. Exceptions are allowed for members who require emergency or urgent care or out-of-area dialysis for ESRD.
All SNPs are required by law to provide prescription drugs. Plans also insist that members choose a primary care doctor and obtain a referral to see a specialist.
Enrollment and Eligibility for Medicare Advantage Plans in Massachusetts
There are specific eligibility requirements and enrollment periods for anyone who wishes to choose a Medicare Advantage Plan in Massachusetts.
Eligibility depends upon the following criteria:
- They must be a U.S. citizen or a permanent resident for longer than five years.
- All plan participants must be 65 years of age or older, or they are eligible because they have suffered a disability at a younger age.
- They must have worked long enough to be eligible for Social Security.
- They need to live in the county where the Medicare Advantage Plan is offered.
- Most Medicare Advantage Plans are not available to anyone who suffers from ESRD, although selecting an SNP is an option if they do not wish to remain under Original Medicare.
A Medicare recipient may select a Medicare Advantage Plan at the following times:
- During Initial Enrollment, a seven-month period that includes the three months before they turn 65, the month they turn 65, and the three months following their birthday
- Annual Enrollment takes place from October 15-December 7. During this window, a Medicare beneficiary who is on Original Medicare can switch to a Medicare Advantage Plan (or switch back to Original Medicare if they are on a Medicare Advantage Plan) or if they are already on a Medicare Advantage Plan, they can change plans
- The Open Enrollment period lasts from January 1-March 31. During this period, Massachusetts seniors who are on a Medicare Advantage Plan can switch plans or switch back to Original Medicare
- During General Enrollment, which lasts from April 1-June 30, only those individuals who have enrolled in Part B for the first time can switch from Original Medicare to a Medicare Advantage Plan
Prescription Drug Coverage
Prescription drug coverage can change from plan to plan with Medicare Advantage Plans:
- Prescription drug coverage is included in most PPOs and HMOs. Some, however, require separate premiums.
- Massachusetts beneficiaries who choose an HMO or PPO that does not provide prescription drug coverage are not allowed to obtain that drug coverage through a separate plan. If they do, they lose their membership in their Medicare Advantage Plan but will still receive coverage through Original Medicare.
- PFFS plans that do not include prescription drug coverage allow their members to enroll in a separate prescription drug plan.
- SNPs are required by law to provide prescription drug coverage.
Medicare Advantage Resources in Massachusetts
Anyone who has decided that they would like to use a Medicare Advantage Plan rather than remain on Original Medicare can feel overwhelmed by the number of available choices. Picking the best plan is a priority, but it can be a confusing and frustrating process.
Fortunately, seniors in Massachusetts have access to several state and local resources whose primary goal is to help them navigate this cornucopia of options.
The Shine Program
This statewide organization relies on several hundred volunteers to provide seniors with the information they need about Original Medicare or Medicare Advantage Plans. They provide free, unbiased advice and information to seniors who have questions about applying for Medicare or Medicare Advantage Plans. They will also provide information and help to the loved ones of seniors in the state who need help with these benefits.
Contact Information: Website | 1-800-243-4636
Seniors in the Boston area looking for help with Medicare or Medicare Advantage Plan choices can contact Age Strong. The counselors and caseworkers for the city who run the program will also provide information about low-cost options as well as referrals to prescription drug plans if needed.
Contact Information: Website | 617-635-4366
MetroWest Meds Program at Kennedy CAC
Focusing on adults who live in the 25 cities and towns of the area known as MetroWest near Boston, this program provides counseling about pharmaceutical drug plans. It can also help seniors on a limited income apply for the appropriate Medicare or MassHealth program.
Contact Information: Website | 508-270-5781
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