Medicare Advantage Plans in Rhode Island

checkmark Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: Jun 25, 2021

 

Medicare Advantage, also known as Medicare Part C,  is an alternative to Original Medicare (Medicare Parts A and B) for hospital insurance and medical insurance. The plans are offered by private insurance companies and approved by Medicare. Medicare Advantage plans in Rhode Island must include both Medicare Part A and Medicare Part B, but typically provide extra benefits that Original Medicare doesn't cover, such as prescription drug coverage (Medicare Part D). Medicare Advantage plans may also pay for dental, vision, hearing services, and more. Plans may have lower out-of-pocket costs than Original Medicare, but costs vary based on the plan selected. In most cases, seniors who opt for Medicare Advantage need to use doctors in the plan's network and service area.

Key Points

  • 1 In 2019, there were 14 Medicare Advantage plans available in Rhode Island.
  • 2 37% of the total Medicare population in Rhode Island were enrolled in Medicare Advantage plans as of 2018.
  • 3 In 2018, Original Medicare spent an average of $9,261 per beneficiary in Rhode Island, which is 8% higher than the national average.
  • 4 Available Medicare Advantage plans range from 21 to 22 across Rhode Island’s five counties.

If you decide to enroll in a Medicare Advantage plan, you’ll have different types of plans to choose from. Medicare Advantage plans in Rhode Island range in cost and coverage levels, so your specific needs will determine which type of plan is right for you. The exact availability of plans also will depend on the health insurance provider and your geographic location. Some options include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-For-Service plans, and Special Needs Plans.

Medicare Advantage Plans in Rhode Island

Types of Medicare Advantage Plans

Rhode Island’s Medicare Advantage program includes numerous HMO and PPO options, as well as some SNPs. Several insurance companies offer these plans to Medicare-eligible seniors. There are specific rules regarding eligibility and enrollment in these plans, especially for SNPs. State and local resources are available to answer questions about how Medicare Advantage works and to help beneficiaries find the right plan for their needs. 

Health Maintenance Organizations (HMO)

HMO plans have a network of providers and facilities that enrollees must use for all non-emergency healthcare services. A network is a group of doctors, hospitals, and medical facilities that contract with a plan to provide services. Typically, plan members who seek medical care outside of the network are responsible for the full cost of care unless it was an emergency or critical care situation. Plan members must also choose a primary care physician. Most HMOs require members to get a referral from their primary care physician for specialist care. 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 also have a network of providers and facilities, but there are fewer restrictions on seeing out-of-network providers. In addition, PPO plans will pay for out-of-network services, although it may be at a lower rate. By using in-network providers, PPO members can save money. PPOs don’t require members to select a primary care physician or to get referrals to see specialists. However, premiums for PPO plans tend to be higher than premiums for HMO plans, and it’s common to have a deductible. 

Private Fee-For-Service Plans (PFFS)

PFFS plans offer the greatest flexibility in deciding which healthcare 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 Rhode Island

Eligibility

Seniors eligible for Medicare Parts A and B are also eligible to enroll in Rhode Island’s Medicare Advantage program if they’re 65 or older or have a qualifying disability and are under 65. Enrollees must also:

  • Live in the plan’s service area
  • Be a U.S. citizen, U.S national, or lawfully live in the U.S. 
  • Not have End Stage Renal Disease, except in certain situations

Rhode Island seniors who receive benefits from Social Security or the Railroad Retirement Board 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.

Enrollment Periods

Medicare Advantage enrollment periods vary, meaning you can only join, switch, or drop a Medicare Advantage plan at a specific time. These include:

  • Initial enrollment period. When you first become eligible for Medicare, you can join a Medicare Advantage plan during your initial enrollment period. This seven-month period begins three months before the month you turn 65 and ends three months after the month you turn 65.  
  • Annual open enrollment period. If you already have Medicare, you can join, switch, or drop a Medicare Advantage plan. from October 15 to December 7 each year.
  • General enrollment period. If you have Part A coverage and you get Part B for the first time (between January 1 and March 31), you can join a Medicare Advantage Plan between April 1 and June 30.
  • Medicare Advantage open enrollment period. From January 1 to March 31 each year, and limited to current Medicare Advantage enrollees, you can change Medicare Advantage plans or switch back to Original Medicare.

Prescription Drug Coverage

Most Medicare Advantage plans in Rhode Island include prescription drug coverage (Part D). 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 get a separate Medicare Part D prescription drug plan. If you want prescription drug benefits, you must join a Medicare Advantage plan that includes prescription drug coverage. Some PFFP plans cover prescription drugs. If the plan offers it, you must get your prescription drug coverage through the plan. Otherwise, you can obtain a separate Part D plan to get coverage. SNPs are legally required to include prescription drug coverage.

Medicare Advantage Resources in Rhode Island

Healthcare is critical for seniors, and Medicare Advantage can be a wise option for those needing health insurance coverage. Rhode Island’s Medicare Advantage program offers numerous plans and options, which can be 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, Rhode Island provides resources at the state and local levels that offer free Medicare counseling to qualified beneficiaries.

The Rhode Island Health Insurance Assistance Program

The Rhode Island Senior Health Insurance Program (SHIP) is part of a national partnership to help consumers make informed healthcare choices. SHIP volunteers provide one-to-one counseling to seniors, adults with disabilities, families, and caregivers. The program is designed to help seniors and adults with disabilities understand healthcare costs and coverage. SHIP counselors are specially trained in all things Medicare with yearly continuing education. Additionally, SHIP helps beneficiaries with limited income apply for subsidized programs, such as Medicaid, Medicare Savings Program, and Extra Help/Low-Income Subsidy.

Contact Information: Website | 888-884-8721

The Rhode Island Office of Healthy Aging 

The Rhode Island Office of Healthy Aging offers health insurance coaching through the Point, the state’s free healthy aging helpdesk. Specialists at the Point can provide counseling to help individuals understand Medicare eligibility and the Medicare enrollment process. Unbiased counselors help individuals compare Medicare plans, Parts A and B, and Part D prescription drug coverage, and explain the enrollment process for Medicare Advantage and Medigap coverage to help seniors find the right Medicare coverage.

Contact Information: Website | 401-462-4444

Rhode Island Senior Medicare Patrol

The Rhode Island Senior Medicare Patrol (SMP) program helps Medicare beneficiaries understand how Medicare fraud, waste, and abuse works. Medicare fraud, waste, and abuse includes incorrect medical documentation and billing by a medical provider to get a higher payment. It also encompasses individuals using another Medicare card to get services or double-billing Medicare and a private insurance carrier for the same services. The Tri-County SMP counselors can assist in reporting suspected cases of Medicare fraud and in educating clients about Medicare fraud. 

Contact Information: Website | 401-462-0194

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Contributing Expert:

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.

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Reviewed by:

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.