Medicare Advantage Plans in Utah

checkmark Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: January 29, 2021


Most seniors are automatically enrolled in Medicare once they reach 65 or have a life-altering disability. The federal government manages Medicare Part A (hospital coverage) and Part B (doctor's visits and outpatient care), and policies are set up to provide equal support to everyone. However, seniors can opt for private Medicare Advantage plans, also known as Medicare Part C. These programs are managed by insurance companies, yet are subject to all the same coverage requirements of Medicare A and B. The benefit of these plans is that they can offer other perks, such as hearing and vision coverage and prescription drug assistance.

Key Points

  • 1 In 2019, there were 30 Medicare Advantage plans available in Utah.
  • 2 36% of the total Medicare population in Utah is enrolled in Medicare Advantage plans as of 2018.
  • 3 In 2018, Original Medicare spent an average of $9,103 per beneficiary in Utah, which is 10% lower than the national average.
  • 4 Available Medicare Advantage plans range from 1 to 29 across Utah’s 29 counties.

Medicare Advantage plans vary in their scope of coverage and availability throughout Utah. Seniors who have had coverage through employer-sponsored programs may be familiar with some of the plan choices. The end goal of selecting a Medicare Advantage plan, or any insurance plan for that matter, is to find the right coverage for your needs while keeping premium costs within your budget.

Medicare Advantage Plans in Utah

Types of Medicare Advantage Plans

Utah offers its residents four types of Medicare Advantage plans: HMOs, PPOs, PFFSs, and SNPs, although PFFS and SNP options are extremely limited. All plans must provide, at a minimum, equal coverage to Original Medicare. Rules and eligibility vary for each category, as do premium costs. When browsing through Utah’s Medicare Advantage program, take time to think about your health needs, including how often you visit your doctor, how many prescription medications you take, and what other types of services would be useful to you. This will help you make the best decision for your situation.

Health Maintenance Organizations (HMO)

While HMO plans may be the most cost-effective in terms of premiums, they come with a lot of restrictions. Members must choose a primary care doctor in the plan’s network, and all health care services should go through this doctor. If a specialist is needed at any time, the primary care doctor must process a referral. Except for life-threatening emergencies, any treatment or medicine that is obtained outside of the HMO network will not be covered or reimbursed. Many HMO plans include prescription drug coverage.

Preferred Provider Organizations (PPO)

Network requirements are much less strict within Preferred Provider Organizations. You don’t need to declare a primary care doctor and can visit any doctor approved by the PPO, including specialists. If you seek medical care outside of the network, you may receive partial reimbursement for the service, although it will be less than if you go in-network. Most PPOs cover prescription drugs, and many have added benefits, such as eyeglasses, dental exams, and hearing aids.

Private Fee-For-Service Plans (PFFS)

PFFS programs offer the greatest amount of flexibility with regard to health care choices; however, they may be hard to find in most regions of Utah. Private Fee-For-Service plans may have a network of doctors and hospitals, or they may not. If your PFFS plan has a network, out-of-pocket costs will be lower if you stay with doctors in-network. If you venture out-of-network, doctors, hospitals, and other health care workers have a choice of whether to accept the PFFS plan’s payment terms. So, if you want to stay with your current doctor and they are not in the PFFS network, you’ll need to make sure they’re willing to accept the plan’s reimbursement. Most PFFS plans offer prescription drug coverage — if they don’t you can add on a Medicare Part D plan.

Special Needs Plans (SNP)

Designed to accommodate the type of services seniors with certain chronic conditions and those in nursing facilities require, SNPs are the most exclusive type of Medicare Advantage plan. Eligibility is limited to those who qualify based on a medical diagnosis or living arrangements. Networks are common in an SNP, and they include doctors who specialize in certain diseases or gerontology. SNPs may cost more than other types of Medicare Advantage plans, but the added services they provide to members with qualifying diseases make them a practical choice for some seniors.

Enrollment & Eligibility for Medicare Advantage Plans in Utah

To sign up for a Medicare Advantage plan in Utah, seniors must meet the following criteria:

  • They must already be eligible for or have Original Medicare Parts A and B. This may be because they reached the age of 65 or have a disabling condition.
  • They must live in an area the plan services.
  • They must not have End-Stage Renal Disease (ESRD) unless they’re applying for an SNP that serves that condition.

During any given year, there are set periods when seniors can enroll in Medicare Advantage plans, depending on whether they’re new to Medicare or interested in changing their current plan.

  • Seniors newly eligible for Medicare can sign up during the Initial Enrollment Period in the seven months that surround their birth month. This includes the three months before their birth month, their birth month, and the three months afterward.
  • Seniors looking to make changes to their current plan or switch from Original Medicare to a Medicare Advantage plan can do so from October 15th to December 7th during Medicare’s Annual Election Period. They can also join or switch Medicare Part D plans at this time. New coverages will begin on January 1st of the following year.
  • For those who already have a Medicare Advantage plan and wish to drop or switch plans, the Medicare Advantage Open Enrollment Period provides another opportunity to fine-tune your health care choices. It runs from January 1st to March 31st.
  • Finally, there are a variety of Special Enrollment Periods available, dependent upon unusual circumstances. Life-changing events, such as being dropped from an employer plan or moving make you eligible for enrollment. Additionally, seniors can switch to a five-star Medicare-rated plan once per year, between December 8th and November 30th. Plan ratings are updated each fall.

Prescription Drug Coverage

Medication expenses make up a large portion of health care costs. Original Medicare Parts A and B do not cover medications (except those given during a hospital stay). Seniors with Original Medicare who wish to have coverage for their prescription drugs must purchase an add-on Medicare D plan. If they want to enroll in a Medicare Advantage plan, they must decide whether or not they want a plan that includes drug coverage. Plans with drug coverage usually have a tiered or ranking system for medications, and reimbursements are based on which tier a medication falls into. SNPs always include prescription drug coverage as part of their added services, and most of the other plans also offer medication coverage. However, if you choose an HMO or PPO plan without drug coverage, you can’t pick up a separate Medicare Part D plan without losing membership in your Medicare Advantage plan. You’ll automatically be placed back into Original Medicare.

Medicare Advantage Resources in Utah

The wide availability of Medicare Advantage plans, along with their range of coverage options and premium costs, makes it difficult for seniors to select a plan. Many people lack the specialized knowledge needed to decipher network requirements, tiered medication formularies, and coverage exclusions. Assistance from experts in the field can often mean the difference between choosing an okay plan and one that exceeds expectations. Fortunately, Utah has several free organizations that can help seniors navigate through the Medicare Advantage Marketplace.

Utah State Health Insurance Assistance Program

When looking into Medicare Advantage plans, it’s essential that seniors get unbiased information, which might not be the case if they meet with an insurance agent. SHIP counselors provide objective counseling and are trained to understand the requirements and benefits of their regions’ plans. They operate through Utah’s Area Agency on Aging offices, which are divided by regions and counties. Seniors can call to set up a one-on-one appointment in their locale.

Contact Information: Website | 800-541-7735

Utah Insurance Department

The state insurance department provides information and assistance with health insurance choices for all consumers, including seniors. The site has various links with useful information, as well as consumer tips on insurance companies in Utah and what questions you should ask an agent. Seniors can contact the Utah Insurance Department with specific questions about insurance companies or their agents or to report insurance fraud.

Contact Information: Website | 801-538-3800

Seniors who need help with legal matters concerning Medicare/Medicaid eligibility or low-income medical programs can contact Utah Legal Services. This nonprofit organization offers free legal support to those of limited means. Other services include help with estate planning, powers of attorney, and paying for nursing home care. The legal aid organization has offices throughout the state, and seniors can fill out an online help request form.

Contact Information: Website | 800-662-4245

National Council on Aging

Using the NCOA Benefits CheckUp tool, seniors in Utah can find available health care benefits based on their ZIP code and compare plans. The NCOA also has a separate educational site, My Medicare Matters, that gives seniors customized advice based on completing a health care assessment. Founded in 1950, this charitable organization focuses on helping older citizens, including political advocacy.

Contact Information: Website | 571-527-3900

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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.