Medicare Advantage Plans in New Jersey
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: November 26, 2020
Medicare Advantage, also referred to as Medicare Part C, provides New Jersey seniors with all the benefits they can expect with Original Medicare Parts A and B but with additional coverage. Medicare Advantage includes hospital and general costs as standard and typically covers the cost of prescription drugs, dental, vision, and hearing services. Medicare Part C is managed by private insurance companies approved by Medicare instead of the federal government.
Key Point Module
- 1 In 2019, there were 49 Medicare Advantage plans available in New Jersey
- 2 22% of the total Medicare population in New Jersey was enrolled in Medicare Advantage plans as of 2018
- 3 In 2018, Original Medicare spent an average of $10,793 per beneficiary in New Jersey, which is 7% higher than the national average
- 4 Available Medicare Advantage plans range from 11 to 43 across New Jersey’s 21 counties
New Jersey’s Medicare Advantage plans differ in cost and coverage, and seniors should compare plans carefully. By laying out the costs and coverage, seniors can evaluate individual plans to find one that best suits their individual needs. Plan availability depends on the geographic location of the participant and the individual health insurance provider. The plan selected must align with the coverage terms set out by Medicare and provide the same benefits, protections and rights as the Original Medicare plan. There are a number of plan options available, including Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-For-Service Plans, and Special Needs Plans.
Medicare Advantage Plans in New Jersey
Types of Medicare Advantage Plans
The Medicare Advantage program in New Jersey offers several different plans, and the availability of these vary across the state. The plans that are typically available to seniors include Health Maintenance Organization (HMO), Planned Provider Organization (PPO), and Private Fee for Service (PFFS). Another type of plan that may be available is the Special Needs Plan (SNP). It’s designed to provide benefits to members with specific illnesses and conditions. When it comes to enrolling with Medicare, each individual plan comes with its own eligibility criteria. Choosing the right plan can get a little confusing, but the good news is that various free counseling services exist to recommend the most suitable option.
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 a primary care physician who will make all treatment decisions and specialist referrals if necessary. An HMO plan may be one of the most restrictive Medicare Advantage plans in New Jersey when it comes to network rules, but these restrictions also make it one of the most affordable. An HMO plan also comes with low or no deductibles.
Planned Provider Organizations (PPO)
The cost of PPO plans are typically higher than an HMO plan, and they always include deductibles. However, they do offer more flexibility with regards to network rules. PPO plans are still tied to a list of specific providers, but this list is typically more extensive than on other plans and offers participants more choice. Participants on a PPO plan will typically receive at least a fraction of the cost of any healthcare services administered by a provider outside of their network. It should be noted, however, that because providers inside the network offer reduced rates to PPO members, they will charge lower coinsurance and co-pay rates. Participants on a PPO plan aren’t required to select a primary care provider or need a referral to see a specialist.
Private Fee-For-Service Plans (PFFS)
For seniors looking for maximum flexibility when choosing a health care provider, PFFS plans are the ideal choice. PFFS plans can come with a partial or full network of providers and even no network at all. On this type of plan, participants are free to choose doctors, hospitals, and other providers outside of a network as long as these providers accept the terms. However, by staying within their plan’s network, participants will usually be subject to lower costs. Healthcare provider payments on a PFFS plan are made on a fee-for-service basis. Decisions on how much members pay for services and how much a plan pays are made by the healthcare provider. This can mean that PFFS plans can come with higher premiums.
Special Needs Plans (SNP)
SNP plans are only available to certain Medicare participants and have stricter enrollment requirements. As a result of their more stringent criteria, SNP plans usually have higher premiums than other plans in the Medicare range. However, these higher costs are offset by the additional 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 specific network of specially selected 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 New Jersey
Seniors eligible to enroll in Medicare Parts A and B will also be eligible for New Jersey’s Medicare Advantage program as long as they satisfy the following rules:
- Be 65 years or older, or if younger, have a qualifying disability
- Live in an area where Medicare Advantage plans are available
- Not be a member of a Medigap plan
- Be a U.S. citizen or permanent resident
- Not have end-stage renal disease — SNPs may still be an option
A number of rules and conditions determine when a participant can enroll in a Medicare plan. Some enrollment periods are open to first-time applicants, while others may only be made available to existing participants looking to change to another plan. Medicare enrollment periods are as follows.
- Initial coverage periods for Medicare Advantage are available to first-time applicants over seven months. This time frame includes the three months before an applicant’s 65th birthday month and the following three months.
- Annual election periods start on October 15 and end on December 17. This enrollment period is only available to Medicare Advantage members looking to change plans or to Medicare members switching to Medicare Advantage for the first time.
- Medicare Advantage Open enrollment periods are only available to existing Medicare Advantage members who are changing plans or moving back to Original Medicare. The period of enrollment runs from January 1 to March 31.
- General enrollment periods are limited to members of Medicare Part A who enrolled in Part B for the first time during an open enrollment period and who are looking to change to Medicare Advantage. The period of enrollment for general enrollment is April 1 to June 30.
Prescription Drug Coverage
Also referred to as Medicare Part D, Medicare prescription drug coverage is an optional benefit available to all Medicare participants. Prescription drug coverage may also be included as part of a package in a Medicare Advantage plan. These plans are known as MA-PD plans. Participants of an HMO or a PPO plan that doesn’t come with prescription drug coverage are not eligible for a stand-alone Medicare Part D plan. Some PFFS plans may include coverage for prescription drugs or allow participants to enroll in stand-alone Medicare Part D coverage. It is a legal requirement for SNPs to include prescription drug coverage.
Medicare Advantage Resources in New Jersey
It’s important that all seniors are able to access healthcare plans that deliver the highest standard of care and are aligned with their individual needs. Medicare Advantage plans offer a sensible choice for any senior seeking a comprehensive and extensive health insurance plan. New Jersey’s Medicare Advantage program gives seniors a broad spectrum of options and plans across the state. Having such a wide selection of plans to choose from is great but could confuse first-time applicants looking to select the right coverage. The good news is that New Jersey has many resources that can help seniors make the right decision.
State Health Insurance Assistance Program (SHIP)
New Jersey’s State Health Insurance Assistance Program (SHIP) extends free health insurance advice to Medicare beneficiaries. SHIP is a statewide program managed by the New Jersey Department of Human Services. Medicare plans and coverage can be confusing, and Medicare beneficiaries often have questions about claims, benefits and supplementary policies. The volunteer counselors at SHIP are trained in all areas of health insurance and have a broad understanding of Medicare plans in New Jersey, including Medicare Advantage.
Contact Information: Website | 1-800-792-8820
New Jersey Citizen Action (NJCA)
New Jersey Citizen Action is a statewide grassroots organization that offers free and impartial advice on a wide range of community topics, including Medicare plans. The organization provides free one-to-one healthcare enrollment assistance and can give seniors advice on choosing the most suitable Medicare plan for their individual needs. Seniors may also be able to get help paying for their insurance. According to NJCA, four out of five people in New Jersey qualify for financial assistance.
Contact Information: Website | 973-273-0315
N.J. Medicare Information & Referral Service
This division of the New Jersey Department of Human Services dispenses free, unbiased Medicare counseling for seniors over the phone. Any questions or concerns that cannot be addressed over the phone are referred to the State Health Insurance Assistance Program (SHIP) office in the relevant county of residence. Thousands of seniors in New Jersey receive assistance each year by calling this information and referral line.
Contact Information: Website | 1-800-792-8820
- 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://nj.gov/health/ Last accessed April 2021
https://njcitizenaction.org/ Last accessed April 2021
https://www.state.nj.us/humanservices/doas/home/hotlinedesc.html 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.