Medicare Advantage Plans in Missouri
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: November 12, 2020
Medicare Advantage provides an alternative to Original Medicare Parts A and B for hospital and general medical care. Missouri seniors who opt to enroll in Medicare Advantage, also known as Medicare Part C, have at least the same benefits as Original Medicare, but these plans typically offer more coverage. Besides hospital and medical costs, many Medicare Advantage plans in Missouri cover prescription drugs, dental, vision, and hearing services. This bundled coverage is offered by Medicare-approved private insurance companies, instead of being managed directly by the federal government. Out-of-pocket costs vary based on the plan selected.
- 1 In 2019, there were 63 Medicare Advantage plans available in Missouri.
- 2 32% of the total Medicare population in Missouri is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $10,205 per beneficiary in Missouri, which is 1% higher than the national average.
- 4 Available Medicare Advantage plans range from 9 to 42 across Missouri’s 114 counties.
Medicare Advantage plans in Missouri range in cost and coverage levels, which allows seniors to compare plans and find the one that meets their unique needs. All plans must follow Medicare’s coverage rules and provide members with the same rights and protections as Original Medicare. The exact availability of plans depends on the health insurance provider and geographic location of the enrollee, with options including Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-For-Service plans, and Special Needs Plans.
Medicare Advantage Plans in Missouri
Types of Medicare Advantage Plans
Missouri’s Medicare Advantage program includes numerous HMO and PPO options, with some PFFS plans and limited SNPs available. Several insurance companies provide these plans to Medicare-eligible seniors. There are specific rules regarding eligibility and enrollment in these plans, especially for SNPs. Still, there are state and local resources available to answer questions about how Medicare Advantage works and help beneficiaries find the right plan for their needs.
Health Maintenance Organizations (HMO)
HMO plans have a network of doctors, hospitals, and other medical professionals, and enrollees must receive all their health care services from network providers. Plan members who seek medical care outside of the network are generally responsible for the entire cost of care unless it was an emergency or critical care situation. Plan participants must also choose a primary care physician, who makes all their treatment decisions and provides specialist referrals if necessary. Although HMOs are the most restrictive regarding network rules, they generally offer the most affordable plans and low or no deductibles.
Preferred Provider Organizations (PPO)
PPO plans typically cost more than HMOs and always have deductibles, but they offer more flexibility. While PPOs also have a list of preferred providers, their networks tend to be more extensive than other plans, and they’ll usually pay at least a portion of the cost for health care services received outside the network. However, PPO participants receive the lowest copay and coinsurance rates with in-network providers because these providers offer reduced rates to plan members. PPOs don’t require members to select a PCP or get referrals for seeing specialists.
Private Fee-For-Service Plans (PFFS)
PFFS plans offer the greatest flexibility in deciding which health care providers to see. These plans may have a partial or full network of providers or may not have a network at all. Either way, plan members may visit any Medicare-approved provider who agrees to the plan’s terms and conditions of payment and still receive full coverage. PFFS plans pay healthcare providers on a fee-for-service basis and decide how much the plan pays and how much members pay for services, so they tend to have higher premiums.
Special Needs Plans (SNP)
SNPs are restricted to certain types of members, and premiums are generally high, but they provide tailored benefits. Seniors who live in nursing homes or require nursing home care, are eligible for both Medicare and Medicaid, or have certain chronic or disabling diseases or illnesses may qualify for an SNP designated for their specific situation. SNPs have targeted provider networks, and members must receive all their care from within this network. These plans typically have limited geographic service areas that may only include a single city or county, so it’s often difficult for qualified individuals to find one.
Enrollment & Eligibility for Medicare Advantage Plans in Missouri
Seniors eligible for Medicare Parts A and B are also eligible to enroll in Missouri’s Medicare Advantage program if they’re at least 65 years old or have a qualifying disability if they’re younger. Enrollees must also:
- Live in an area where Medicare Advantage plans are sold
- Not be enrolled in Medigap insurance
- Be a U.S. citizen or permanent resident
- Not have end-stage renal disease, but SNPs may still be an option
Missouri seniors who receive Social Security or Railroad Retirement Board benefits are automatically enrolled in Medicare Parts A and B when they turn 65. They can sign up for Medicare Advantage before this occurs or switch plans during a Medicare-approved enrollment period.
Individuals receiving disability insurance must do so for 24 months in order to qualify for Medicare.
Medicare Advantage enrollment periods vary, meaning they may be open to first-time applicants or only open to existing members who wish to change plans.
- Initial coverage election periods are for first-time joiners and run for a seven-month period, which covers the three months prior to an enrollee’s 65th birthday month and the three months following.
- Annual election periods are from October 15 to December 7 and limited to current Medicare recipients switching to Medicare Advantage for the first time, or current Medicare Advantage members changing plans.
- Open enrollment periods are from January 1 to March 31 and limited to current Medicare Advantage recipients changing plans or switching back to Original Medicare.
- General enrollment periods are from April 1 and June 30 and limited to individuals who already had Medicare Part A, enrolled in Part B for the first time during the open enrollment period and are switching to Medicare Advantage.
- Special Election Periods: Various specific circumstances may allow you to leave an existing MA plan or enroll in a new MA plan.
During the Open Enrollment Period the following can occur:
- Anyone who has (or is signing up for) Medicare Parts A or B can join or drop a Part D prescription drug plan.
- Anyone with Original Medicare (Parts A & B) can switch to a Medicare Advantage plan.
- Anyone with Medicare Advantage can drop it and switch back to just Original Medicare (Parts A & B).
- Anyone with Medicare Advantage can switch to a new Medicare Advantage plan.
- Anyone with a Part D prescription drug plan can switch to a new Part D prescription drug plan.
Prescription Drug Coverage
Medicare Advantage plans in Missouri may bundle prescription drug coverage into a Medicare Advantage Prescription Drug plan or MA-PD. Prescription drug coverage may be included in the premium or require a separate premium. HMOs and PPOs without drug coverage don’t allow members to obtain stand-alone Medicare Part D prescription drug plans. Beneficiaries lose their Medicare Advantage and revert to Original Medicare if they enroll in Part D plans. PFFS plans may include prescription drug coverage, otherwise, they allow beneficiaries to enroll in a separate Medicare Part D plan. SNPs are legally required to include prescription drug coverage.
Medicare Advantage Resources in Missouri
Health care is immensely important for seniors, making Medicare Advantage highly beneficial to those needing health insurance coverage. Missouri’s Medicare Advantage program offers numerous plans and options, which often makes it confusing for first-time enrollees and those needing to switch to plans that better fit their needs. To help seniors navigate the enrollment process and understand their options, Missouri provides resources at the state and local levels that offer free Medicare counseling to qualified beneficiaries.
CLAIM stands for Community Leaders Assisting the Insured of Missouri and is offered through a contract with the Missouri Department of Commerce & Insurance as Missouri’s official State Health Insurance Assistance Program (SHIP). This nonprofit offers free, confidential, and unbiased counseling to Missourians with questions about Medicare. Volunteers receive extensive training to become certified Medicare counselors and help beneficiaries with applications and enrollment in Medicare, Medicare Advantage, Medigap, and Medicaid/MO HealthNet. They also assist with Medicare and Medicare Advantage claims and the Medicare appeals process.
Contact Information: Website | 800-390-3330
Care Connection for Aging Services
Care Connection for Aging Services provides Medicare and Medicaid counseling to help individuals understand their eligibility, the available benefits, and the enrollment process. Certified volunteers, insurance counselors, and care managers help beneficiaries compare Medicare plans, Parts A and B, and Part D prescription drug coverage, and explain the enrollment process for Medicare Advantage and Medigap coverage. They also provide benefits education and workshops and direct the statewide Senior Medicare Patrol to help detect, prevent, and report health care fraud. Seniors can call or email [email protected] to speak with a certified counselor.
Contact Information: Website | 800-748-7826
St. Louis Oasis
St. Louis Oasis offers free, confidential assistance with Medicare questions at its St. Louis-area offices. State-certified volunteer insurance counselors offer unbiased counseling to Medicare beneficiaries, including first-time Medicare and Medicare Advantage enrollees and those needing assistance with plan changes and claims. Medicare counselors are available year-round to assist beneficiaries from four BJC hospital locations, including Alton Memorial Hospital, Barnes-Jewish Hospital, Barnes-Jewish West County Hospital, and Christian Hospital. It also offers free informational programs at various locations. Seniors can schedule one-on-one counseling appointments by calling 314-362-7587.
Contact Information: Website | 800-390-3330
SeniorAge Area Agency on Aging
The SeniorAge Area Agency on Aging serves 17 counties throughout southwest Missouri. The agency offers “New to Medicare” educational programs and insurance counseling by trained navigators who help with Medicare and Medicare Advantage enrollment. Services also include virtual “New to Medicare” enrollment counseling and free assistance to help individuals find the best prescription drug plan to meet their needs and budgets. Complimentary SeniorAge classes are held from 9:00 a.m. to 11:30 a.m. at 1735 S. Fort in Springfield, with reservations required. Open enrollment assistance is available by appointment beginning September 1 of each year.
Contact Information: Website | 417-862-0762
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