Medicare Advantage Plans In Ohio
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: February 10, 2021
Medicare Advantage plans in Ohio offer seniors enhanced options beyond Medicare Parts A and B. Sometimes referred to as MA or Part C, many Medicare Advantage plans combine hospital and medical with prescription drug coverage, also known as Part D. Depending on the plan, additional benefits may include gym memberships, hearing resources, transportation to medical appointments, vision, and dental. Medicare-approved private insurance companies are responsible for managing the individual Medicare Advantage plans, and costs are dependent on the specific coverage.
Key Point Module
- 1 In 2019, there were 122 Medicare Advantage plans available in Ohio.
- 2 37% of the total Medicare population in Ohio is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $10,288 per beneficiary in Ohio, which is 2% higher than the national average.
- 4 Available Medicare Advantage plans range from 25 to 77 across Ohio’s 88 counties.
Ohio seniors new to Medicare Advantage can weigh coverage options and costs before deciding on a plan that meets their needs. While selections typically include HMOs, PPOs, PFFSs, and SNPs, choices may vary based on the enrollee’s geographic location and the carrier’s availability. Medicare and private insurers agree on a set payment schedule to cover the beneficiary’s care each month. Although each plan has specific rules, they must all adhere to Medicare’s guidelines regarding eligibility and enrollment.
Medicare Advantage Plans in Ohio
Types of Medicare Advantage Plans
Ohio’s Medicare Advantage plans encompass a variety of options, including HMOs, PPOs, PFFSs, and SNPs, each of which is managed by private insurers. Specific rules differ between plan types. Carriers within the same type of organization may also stipulate their own guidelines, adding to the complexity of the decision-making process. However, beneficiaries of Medicare Advantage’s programs enjoy the same protections as those enrolled in Original Medicare.
Health Maintenance Organizations (HMO)
HMO plans offer beneficiaries a network of providers and facilities, including doctors and hospitals. Members must choose a primary care physician to manage general care and write necessary referrals for specialists. Individuals are required to remain in-network when seeking treatment, with a few exceptions. They may be covered for out-of-network emergency services, as well as out-of-area dialysis. Most HMOs include prescription drug coverage. If members want prescription benefits, they should choose one of those plans. Medicare does not permit plan participants to enroll in a Medicare Advantage HMO and Plan D. While HMOs are among the most restrictive plans, they offer members lower-cost options for premiums, deductibles, and co-pays.
Preferred Provider Organizations (PPO)
Enrollees wanting more flexibility might want to consider a PPO plan. PPOs are more expensive than HMOs, but they also offer members greater latitude with individual choices. Members do not need to select a primary care physician, and it is not necessary to obtain a referral before seeing a specialist. While PPOs also offer in-network care, participants have the option of going out-of-network for health services. However, co-pay and coinsurance rates are lower if they remain in-network. As with HMOs, PPO plans typically include prescription drug coverage. If they do not, it is not permissible for plan participants to purchase stand-alone Part D insurance.
Private Fee-For-Service Plans (PFFS)
PFFS plans have prearranged rates set with providers, as well as the insured’s co-pay and coinsurance responsibilities. Members have the option of seeing the physician or facility of their choice, as long as the terms of the plan are accepted. Some PFFSs operate as part of a network. While beneficiaries are free to choose where they receive care, their costs are lower with in-network services. Many PFFS plans also include prescription drug coverage. Participants are free to select Part D coverage, if necessary, without penalty. Individuals pay higher premiums with PFFS coverage.
Special Needs Plans (SNP)
SNPs are specifically designed for seniors and other eligible individuals with unique circumstances. Plans are available for those experiencing chronic health conditions, including heart failure, dementia, and HIV/AIDS. They are also tailored for beneficiaries who qualify for both Medicare and Medicaid, as well as nursing home residents. SNPs are legally responsible for including prescription drug coverage with their plans. To qualify for full coverage, members are required to receive care with in-network providers. Medicare Advantage’s SNPs typically cost more than other types of plans, and they’re only available in a select number of geographic locations.
Enrollment & Eligibility for Medicare Advantage Plans in Ohio
Ohio residents must meet the following requirements to enroll in a Medicare Advantage program.
- They must be eligible for Medicare Parts A and B.
- They must be at least 65, or younger with a qualifying condition.
- They must be U.S. citizens or permanent residents with a minimum of five consecutive years of residency.
- They must not be enrolled in a Medigap plan.
- They must live within the geographic area.
Seniors receiving Railroad Retirement or Social Security benefits when they turn 65 are automatically enrolled in Medicare Parts A and B. They may switch to a Medicare Advantage plan during open enrollment.
Seniors and other eligible individuals have greater accessibility to Medicare benefits and avoid paying penalties when they adhere to the specific enrollment periods.
- Initial enrollment takes place during the three months prior to an enrollee’s 65th birthday, the month of their birthday, and the three months following their birthday.
- During the annual election period, from October 15th through December 7th, current Medicare participants can make their initial move to a Medicare Advantage plan. Medicare Advantage beneficiaries may also change plans.
- The annual open enrollment period occurs between January 1st and March 31st. Current Medicare beneficiaries are permitted to change plans or revert to Original Medicare.
- The general enrollment period between April 1st and June 30th is only open to individuals who had Medicare Part A and completed registration for Plan B during the open enrollment period, as well as those who decide to switch to Medicare Advantage.
Prescription Drug Coverage
Medicare Advantage prescription drug plans for Ohio seniors are operated by Medicare-approved private insurance carriers. Medicare Advantage plans, including prescription drug coverage, are called MA-PDs. Each program has specific criteria for its prescription plan. HMOs and PPOs that do not have a drug plan included do not permit Medicare Advantage members to also enroll in Medicare Part D. Those who attempt to sign up for both are dropped from Medicare Advantage and reinstated in Original Medicare. PFFS plans may or may not include prescription coverage. The difference is that beneficiaries are permitted to also enroll in Part D if necessary. SNPs are required by law to include a prescription drug package with their plans.
Medicare Advantage Resources in Ohio
Trying to decide which Medicare Advantage plan is the most beneficial for individual needs can be overwhelming for Ohio seniors, particularly new enrollees. There are a number of free services available throughout the state to help Medicare-eligible seniors navigate the complex system.
Ohio Senior Health Insurance Information Program (OSHIIP)
OSHIIP’s trained counselors help seniors choose the right Medicare benefits for their unique situation. The advisors offer unbiased health insurance guidance for Original Medicare, Medicare Part D, Medicare Advantage, and Medicare’s supplemental programs. The program’s counselors are committed to empowering individuals by providing them with the information they need to make educated decisions about their health care. One-on-one and virtual counseling sessions, as well as Medicare webinars, are also available.
Contact Information: Website | 800-686-1578
Jewish Family Service
The Cincinnati service’s state-approved specialists help those who have questions about or need assistance with choosing the right plan. Its licensed social workers are also available to help individuals and their families and caregivers through the eldercare process. Jewish Family Service’s case managers are certified through OSHIIP and qualified to answer questions related to Medicare coverage for seniors and younger individuals with disabilities, prescription drug coverage, supplemental plans, and Medicare Advantage. The center’s Jewish Family Service Aging and Caregiver Services also answers questions about Social Security, and it assists with managing bill payments, coordinating in-home care, and determining appropriate living arrangements.
Contact Information: Website | 513-469-1188
Medicare Rights Center
This national nonprofit organization works to ensure that people with disabilities and seniors have access to affordable health care. In operation since 1989, its team offers objective advice, educational guidance, and advocacy for individuals applying for Original Medicare and Medicare Advantage programs. The center’s trained staff and volunteers answer questions about initial enrollment, Medicare and private insurance coordination, eligibility, and benefit denial appeals. It also provides online resources, such as the Medicare Minute, a monthly update delivered to local organizations, including libraries, faith-based institutions, and senior centers intended to help support Medicare recipients and their caregivers.
Contact Information: Website | 800-333-4114
- Sources [-]
https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans Last accessed April 2021
https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b Last accessed April 2021
https://www.medicare.gov/blog/medicare-enrollment-period-2020 Last accessed April 2021
https://www.medicare.gov/sign-up-change-plans/joining-a-health-or-drug-plan# Last accessed April 2021
https://insurance.ohio.gov/wps/portal/gov/odi/consumers/medicare/01-oshiip Last accessed April 2021
https://www.jfscinti.org/ Last accessed April 2021
https://www.medicarerights.org/ 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.