Medicare Advantage Plans in Vermont

checkmark Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Updated: Jul 18, 2021

 

When people in Vermont turn 65 or start receiving Social Security benefits, they can enroll in a Medicare Advantage plan, also known as Medicare Part C. Medicare Advantage plans have all of the same features as Original Medicare Parts A and B. They may also provide additional coverage for prescription drugs, as well as dental, vision and hearing services.

 

While Original Medicare is available through the government, Medicare Advantage plans are offered by private health insurance companies. These companies are required by law to provide the same hospital and medical benefits as Original Medicare.

Key Points

  • 1 In 2019, there were nine Medicare Advantage plans available in Vermont.
  • 2 9% of the total Medicare population in Vermont is enrolled in Medicare Advantage plans as of 2018.
  • 3 In 2018, Original Medicare spent an average of $7,727 per beneficiary in Vermont, which is 23% lower than the national average.
  • 4 Available Medicare Advantage plans range from 11 to 13 across Vermont’s 14 counties.

In Vermont, as in every state, an eligible beneficiary can choose from four different types of Medicare Advantage plans. Some of these plans may be familiar to people who have received their health care through their employment in the past. Some require you to use only in-network health care providers, while others provide greater choice but cost more. Many of these plans include Medicare prescription drug coverage, while others do not.

There are specific periods when you can either select a Medicare Advantage plan or move from Original Medicare to Medicare Advantage or vice versa.

Medicare Advantage Plans in Vermont

Types of Medicare Advantage Plans

Every senior who is thinking of enrolling in Medicare Advantage or moving from Original Medicare to Vermont’s Medicare Advantage program needs to ask themselves some important questions:

  • Do I want a plan that only covers in-network health care providers and does not provide the option of going out-of-network?
  • Should I select a plan that has a low premium but offers fewer additional benefits? Some plans might have zero premiums, and others might charge hundreds of dollars.
  • Do I need a plan that offers Medicare prescription drug coverage?
  • Do I plan to travel or spend the winter away from my primary care physician?

Medicare Advantage plans can vary from county to county in Vermont. Depending on where you live, you may have more plans to choose from than in other counties.

Health Maintenance Organizations (HMO)

HMO plans in Vermont require you to choose health care providers from the HMO’s network. Referrals are necessary to see a specialist, and you need to name a primary care physician. The only exceptions to this rule are for emergencies or out-of-area urgent care. Most of these plans offer prescription drug coverage, but not all of them do. If you want medication coverage, you must select a plan that includes it. HMO plans usually cost less, and many do not require a premium; however, HMO participants still need to pay Original Medicare’s Plan B premium and, if applicable, the Part A premium.

Preferred Provider Organizations (PPO)

PPOs also offer in-network access to health care providers, but they allow the option of seeking care from outside the network. This does not mean that the PPO will cover all costs for out-of-network health care. Instead, the plan will cover a certain amount, and plan participants are then required to cover the rest. Individuals who choose a Medicare Advantage PPO plan do not need to name a primary care physician or, in most cases, obtain a referral to see a specialist. PPO plans may also offer additional benefits at an additional cost.

Private Fee-For-Service Plans (PFFS)

Anyone interested in a plan with fewer restrictions may want to consider a PFFS plan. These plans allow flexibility when it comes to providing health care, but they also set limits on what they will pay healthcare providers. Companies that provide PFFS plans often contract with a network of providers. Plan participants may seek health care from doctors out-of-network, but some healthcare workers may refuse service based on the plan’s payment terms. All PFFS networks must provide emergency care. Most, but not all, PFFS plans offer prescription drug coverage. If they don’t, you can add a Medicare Part D plan.

Special Needs Plans (SNP)

SNP plans are tailored to people who have specific medical conditions or diseases. These plans provide coverage for the specific medical needs of each participant. Plan members must choose the SNP’s in-network health care providers, although (as with the other types of plans) exceptions are made for emergency or out-of-network urgent care. Out-of-network dialysis is also provided for End Stage Renal Disease (ESRD). Plan members must choose a primary care doctor and obtain referrals to see specialists. SNP’s are required by law to provide prescription drug coverage.

Enrollment and Eligibility for Medicare Advantage Plans in Vermont

To receive Original Medicare or to select a Medicare Advantage plan, an individual must  meet the following criteria:

  • They must be 65 years of age or older or be in receipt of Social Security disability benefits.
  • They must be a U.S. citizen or a permanent resident for at least five years.
  • They must have worked enough hours to qualify for Social Security.
  • They must be enrolled in Medicare Part A and Part B or be eligible to enroll.
  • They must live in the county where the plan is offered.

During any given year, there are specific periods when an individual can enroll in a Medicare Advantage plan in Vermont:

  •  The Initial Enrollment Period occurs around a seven-month period, including the three months before a senior turns 65, the month they turn 65 and the three months following their 65th birthday.
  • The Annual Election Period runs from October 15th to December 7th. People can move from Original Medicare to a Medicare Advantage plan during this time, or they can shift from one Medicare Advantage plan to another.
  • The Medicare Advantage Open Enrollment Period runs from January 1st to March 31st. During this period, seniors can shift from one Medicare Advantage plan to another or return to Original Medicare.
  • The Special General Enrollment Period runs from April 1st to June 30th and only involves individuals who enrolled in Part B during open enrollment and want to select a Medicare Advantage plan.

Prescription Drug Coverage 

Many Vermont Medicare Advantage plans offer prescription drug coverage, but not all of them do, and the coverage may differ from plan to plan. Medicare Part D is the optional drug coverage that accompanies Original Medicare. 

  • HMO and PPO plans tend to include prescription drug coverage but may require separate premiums.
  • HMO and PPO plans that don’t cover prescription medications don’t allow their members to join a separate Part D plan. If members enroll in Part D coverage, they lose their Medicare Advantage plan and are automatically placed back into Original Medicare.
  • Like HMO and PPO plans, some PFFS plans offer prescription drug coverage. However, if a plan does not provide coverage, members can enroll in a separate Part D program.
  • SNP plans are legally required to provide prescription drug coverage.

Medicare Advantage Resources in Vermont

Enrolling in a Medicare Advantage plan can be confusing for seniors, with all of the options available, the range of coverages, and higher premiums. Original Medicare has one plan, but there are numerous Medicare Advantage plans to choose from in Vermont. You can also switch Medicare Advantage plans at some point, or you can return to Original Medicare if you’re not happy with your Medicare Advantage plan. All in all, figuring it out can be a frustrating process.

Vermont has many resources to help seniors sort through their options and answer their questions about Medicare and Medicare Advantage.

Vermont RX Card

Vermont RX Card is the statewide free prescription drug assistance program and is open to everyone in the state. It was established in 2001 to provide drug coverage for the uninsured, and it is accepted at over 56,000 pharmacies nationwide. Seniors who are enrolled in plans without drug coverage and who take minimal medications may be interested in this option.

Contact information: Website | 800-931-4052

The Vermont Association of Area Agencies on Aging

This agency comprises five nonprofit Agencies on Aging located throughout Vermont. It provides seniors with information on subjects, such as Medicare and Medicare Advantage, as well as caregiver support, transportation, Senior nutrition programs, home health services, and support for veterans. These agencies have certified State Health Insurance Program (SHIP) staff on hand to counsel specifically about Medicare benefits. All counselors are completely unbiased, and they often lead area workshops, as well.

Contact information: Website | 800-642-5119

Vermont Senior Health Line

Seniors or their family members can call the nonprofit helpline at any time to speak with experts on a variety of resources, including Medicare and Medicare Advantage plans, adult day care, legal services, the location of senior centers, housing transportation, and mental health services.

Contact information: Website | 800-642-5119

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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.