Medicare Advantage Plans in Minnesota
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: February 3, 2021
Medicare Advantage plans, or Medicare Part C, are insurance plans that cover the same healthcare services that Original Medicare (Medicare Part A and Medicare Part B) cover, but with extra benefits, including dental care, vision, and even gym memberships. These plans are sold through private insurance companies but must meet Medicare standards. Medicare Advantage plans are flexible and allow enrollees to change plans and coverage as their needs change. Each plan may have different eligibility guidelines, but applicants must already be enrolled in regular Medicare before enrolling.
- 1 In 2019, there were 69 Medicare Advantage plans available in Minnesota.
- 2 56% of the total Medicare population in Minnesota is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $9,126 per beneficiary in Minnesota, which is 10% lower than the national average.
- 4 Available Medicare Advantage plans range from 15 to 48 across Minnesota’s 87 counties.
Enrollment in Medicare Part C is optional, and the program offers choices for those who wish coverage beyond what Original Medicare offers. However, unlike Original Medicare, plans in each state differ, and even within each state, certain options may only be available in select regions. Many of the Medicare C plans may look familiar to applicants who have previously held private insurance or received insurance coverage through an employer. Many of the insurance companies that offer these plans also sponsor corporate plans and individual insurance.
The premium for Medicare part C is the responsibility of the insured, including any applicable copay for doctor visits. The costs for each plan can change from year to year, even if the plan’s coverage remains the same, so it’s important to read over plan documentation each year to prevent any gaps in insurance coverage due to lack of funds.
Medicare Advantage Plans in Minnesota
Types of Medicare Advantage Plans
Medicare Advantage plans in Minnesota vary, although there are four specific categories of coverage — each with rules about which providers an insured can see and the kinds of care and medication covered, including hospitalization. The four types are Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-For-Service Plans (PFFS), and Special Needs Plans (SNP). While there are similarities among the choices, every insurance company is different, so coverage of certain health conditions may vary according to the provider. Eligibility and exclusions are diverse for each plan, as well.
Minnesota offers senior residents several state and local resources to help them understand each plan’s characteristics and where to find coverage in their area. For seniors who need coverage when traveling, or who spend part of the year in warmer climates, assistance is also available to help them find plans that provide healthcare coverage on the road.
Health Maintenance Organizations (HMO)
HMO insurance plans work with local physicians and specialists in a network, a business relationship with negotiated rates for services. Those enrolled in HMO insurance must select only from providers within the network in order to receive insurance coverage, and the network provider submits its billing to the insurance company. This coverage is one of the most restrictive and may not cover individuals if they travel out of network or if they opt for out-of-network health care (unless in cases of an emergency). Some HMO plans include prescription drug coverage in their package, while others do not.
Preferred Provider Organizations (PPO)
Like HMO plans, Medicare Advantage PPO insurance also has a network of providers that partner with each insurance company, including specialists and hospitals. However, while reimbursement rates for network physicians are lower for policyholders, the insured may choose to receive care from an out-of-network provider yet still be covered by the PPO insurance plan. This differs from HMO coverage, which requires individuals to pay out-of-pocket when visiting an out-of-network doctor. Many times expenses for prescription medication are included as part of the insurance plan. It should be noted that the cost share for individuals who receive out-of-network care may be higher.
Private Fee-For-Service Plans (PFFS)
PFFS plans also have a network of healthcare providers, and within this network, any member provider will treat any policyholder. However, those enrolled in PFFS plans can also seek treatment from out-of-network providers, and while they may have to pay more for these services than for services in-network, the insurance company will pay part of these costs. PFFS plans may cover prescription drug coverage, and, if they don’t, enrollees can purchase a stand-alone Medicare D plan (unlike HMO and PPO plan types). However, these plans have higher premiums than PPOs and HMOs, and deductibles and co-pays may be higher under this plan.
Special Needs Plans (SNP)
Special Needs Plans are the only plans that cover care for subscribers living in long-term care facilities, such as assisted living and memory care communities or nursing homes. To qualify for these plans, seniors must be residents of one of these types of communities and be enrolled in either Medicaid, Medicare, or both. Select SNP plans are also available for those with chronic conditions (with a few exclusions), offering comprehensive care to meet the enrollees’ needs. SNP plans always include prescription drug coverage as part of their service. Participants in these plans must receive coverage from network providers only, however, the premiums for these plans are typically high. In addition, SNP may not be available in every Minnesota county, and eligibility requirements are stricter.
Enrollment & Eligibility for Medicare Advantage Plans in Minnesota
Minnesota seniors 65 years and older are eligible to apply for Medicare Part C plans. To qualify, applicants must first be enrolled in Original Medicare Part A and B and not have active Medigap insurance. Other stipulations for coverage include:
- Applicants must receive Social Security or be eligible for Social Security
- Be 65 years old or older
- Not have the End Stage Renal Disease (ESRD); however, applicants who do have this condition may be able to apply for an SNP plan
- Individuals who have been receiving disability benefits for 24 months will become eligible for original medicare. Once those individuals have Medicare Parts A and B, they are eligible for a Medicare Advantage plan.
Applicants have different enrollment options, so it’s important to pay attention to open dates to ensure you get your plan selection.
- The IEP (Initial Enrollment Period) for Medicare Part C is the same period as Original Medicare. Most seniors choose to enroll in Medicare at this time, which begins three months before their 65th birthday month and lasts for the three months following. Coverage for Original Medicare and Medicare Advantage begins the first of the month following enrollment, so seniors are urged to select their coverage and enroll promptly, to avoid any gaps in coverage.
- Medicare Advantage Open Enrollment Period: January 1 – March 31. This is an open enrollment period open to anyone, regardless of their birth month, allowing seniors to change their plan, enroll in a new one, or drop their coverage entirely. Medicare Part D, the prescription drug coverage plan type, also has open enrollment at this time.
- Medicare Annual Enrollment Period (AEP): October 15 – December 7. This enrollment period also allows seniors to change from one plan to another, or drop coverage or enroll for the first time. Other options include changing from Medicare Part C back to Traditional Medicare or making changes to their Medicare Part D coverage.
- General enrollment period, extension: April 1 and June 30. Seniors who enrolled in Medicare Part B during the Part B signup from January 1 to March 31 can use this period to join a Medicare Advantage plan.
- Medicare Special Enrollment Periods. These are limited enrollment periods, and not every senior will qualify. Seniors are encouraged to speak with a local Minnesota insurance agent about enrollment eligibility if they have extenuating circumstances, such as a loss of employer coverage.
Prescription Drug Coverage
Original Medicare participants who want drug coverage must purchase a separate plan called Medicare Part D. While some of the Medicare Part C options (specifically SNP plans) do cover prescription drugs, not every Medicare Advantage plan does. HMO and PPO plan members do not have the option to purchase a separate stand-alone Medicare Part D plan, so if you need prescription drug coverage, make sure it’s included. Most PFFS plans carry drug coverage, however, if they don’t, seniors can purchase a separate Medicare Part D plan.
Furthermore, while some Minnesota Medicare Advantage plans will cover medications, each one is different, and plans change year over year. Most policies that do provide prescription drug coverage have a formulary listing of covered medications. Therefore, enrollees are advised to read each plan’s coverage carefully and speak with an insurance agent about coverage for their specific medications. The only Medicare Advantage plans legally required to pay for prescription drugs are the SNP programs.
Medicare Advantage Resources in Minnesota
Comprehensive health care is important for Minnesota seniors, and Medicare Advantage plans are designed to give seniors options for coverage as their needs change. However, the language of the plans can be confusing and filled with jargon, which many seniors may have difficulty understanding. Plus, most insurance policy coverage information uses medical-specific terms, not layman language, and some applicants may be unsure which health conditions are covered.
Minnesota offers help for first-time Medicare applicants and seniors considering Medicare Advantage to find a plan that provides them coverage within their budget. Minnesota has several resources at both the state and local levels, including professional counseling to help with the application process and policy review.
Minnesota State Health Insurance Assistance Program (SHIP)
The Minnesota State Agency on Aging administers the SHIP program, which helps seniors find the right kind of insurance policy for their needs and walks them through the application process. Representatives also help seniors understand the policy language for each plan that Minnesota insurance companies offer, including conditions that are covered and certain exclusions. The counselors at SHIP don’t endorse any one insurance agency or plan, but rather guide those eligible to options that best suit current and potential needs. Appointments are available virtually and in-person for individuals already enrolled in Medicare, those considering it, and those looking at programs on behalf of a loved one.
Contact Information: Website | 800-333-2433
Minnesota Department of Commerce – Insurance
This state-funded organization licenses and regulates insurance providers and allows them to operate within Minnesota. Independent counselors offer guidance for applicants, including seniors looking for Medicare programs. Seniors or those acting on behalf of seniors can contact the Department of Insurance to verify the validity of a policy or insurer and access consumer education information.
Contact Information: Website | 651-539-1500
Minnesota Health Information Clearinghouse
The Clearinghouse provides an overview of health coverage options, including comparing Original Medicare and Medicare Part C plans for seniors. Unbiased advocates help applicants with grandfathered coverage, transitioning from employer or COBRA insurance plans to Medicare, and options specific to Minnesota residents.
Contact Information: Website | 651-201-5000
- Sources [-]
https://www.healthcare.gov/glossary/health-maintenance-organization-hmo/ Last accessed April 2021
https://www.healthcare.gov/glossary/preferred-provider-organization-ppo/ Last accessed April 2021
https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans 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.