Call us today at (973) 500-3708

Need an Insurance solution? Call us today at (973) 500-3708

Medicare Advantage

Medicare Advantage (Part C) plans are an all-in-one alternative to Original Medicare. All advantage plans are required to provide the same benefits as Part A and Part B, and some offer additional benefits, such as, but not limited to:

  • Nutrition programs
  • Fitness memberships
  • Dental, vision, and hearing
  • Prescription drug coverage
  • Transportation to doctor’s visits

Who Offers Medicare Advantage Plans

Advantage plans are offered by private insurers that Medicare approves. The specific benefits you’re eligible for will depend on your plan providers and the area in which you live.

Who Is Eligible for Medicare Advantage

If you’re eligible for Medicare Parts A and B, you’re eligible for a Medicare Advantage plan. You must be enrolled in BOTH Parts A and B before you can buy a program. Also, you can’t drop Part B.

When Can You Enroll in Medicare Advantage

There are select times when you can join an Advantage plan or make changes to the plan you already have. The best time to enroll is when you’re first eligible for Medicare or turning 65. This will be during your Initial Enrollment Period.

Suppose you already have an Advantage plan but are unhappy with it. In that case, you can make a change during the Medicare Advantage Open Enrollment Period — January 1 to March 31 yearly. During this window, you can:

  • Switch to a different Advantage plan — with or without prescription drug coverage
  • Return to Original Medicare and, if necessary, also enroll in a Part D plan

Your new coverage will take effect on the first day of the month after your plan receives your request.

You can also make changes to your plan during the Annual Open Enrollment Period from October 15 to December 7.

Finally, some circumstances qualify beneficiaries for a Special Enrollment Period, during which they can sign up for an Advantage plan.

Medicare Advantage vs. Medicare Supplements

Medicare Advantage and Medicare Supplements are excellent choices for taking your Medicare coverage the extra mile. However, while both are great, you can’t have them together. You must pick one or the other. There are fundamental differences, and with these, you can decide which one is a better fit for you.

What Is The Purpose of These Medicare Plans

Medicare Advantage is a bundle package that must cover what Original Medicare (Part A and Part B) does. They may also include extra coverage for dental, vision, and hearing services. Some plans include nutrition programs, gym memberships, and prescription drug coverage.

Medicare Supplements minimize out-of-pocket costs for what Medicare already covers. Such charges include:

  • Part A and Part B coinsurance and copayments
  • Part A and B deductibles
  • Complete coverage for the first three pints of blood for transfusions

This sometimes eliminates out-of-pocket costs. It’s not a policy that stands on its own, so you won’t be able to drop Original Medicare to get a Medicare Supplement policy by itself.

How Can You Enroll

Medicare Advantage and Medicare Supplements have their time windows for enrolling.

You can enroll in a Medicare Advantage plan during the Initial Enrollment Period, which starts three months before your 65th birthday and lasts until three months after you turn 65. If you don’t enroll during this time, you’ll need to wait until the Annual Enrollment Period to join, which is from October 15 to December 7. Also, you must already be enrolled in Original Medicare before enrolling.

Like Medicare Advantage, Medicare Supplements also require enrolling in Original Medicare first. Joining a Medicare Supplement plan has a much narrower window of opportunity. You have six months after joining Medicare Part B to enroll. This is also called the Medigap Open Enrollment Period. After this time passes, you may not be able to get a Medicare Supplement plan.


Many, but not all, Medicare Advantage plans require staying within a provider network. Some allow out-of-network coverage but at a higher cost.

Medicare Supplements offer coverage in any healthcare facility that accepts Medicare.

Coverage Types

Medicare Advantage offers policies that function differently. For example, a Preferred Provider Organization (PPO) plan gives you extra savings for specific healthcare providers. On the other hand, a Private Fee-for-Service (PFFS) plan determines costs ahead of time.

Medicare Supplements have ten plans, labeled Plan A, B, C, D, F, G, K, L, M, and N. The difference isn’t in how they function but in the extent of the coverage they offer. They’re only effective after your Medicare plan covers what it can.

Types of Medicare Advantage Plans

There are many types of Advantage plans for different health needs. The most common programs are:

Health Maintenance Organization (HMO) Plan

HMOs usually require you to see doctors in the plan’s “network” providers and get referrals from a primary care physician. If you go outside the network, you’ll likely pay more.

Preferred Provider Organization (PPO) Plan

In most cases, PPOs don’t require referrals from a primary care doctor, and you pay less if you use doctors in the plan’s network.

Private-Fee-For-Service (PFFS) Plan

This type of plan lets you visit any Medicare-approved hospital, doctor, and provider that accepts the plan’s payment, terms, and conditions and says they’ll treat you.

Special Needs Plan (SNP)

Other Advantage plans include Medicare Medical Savings Account plans and Medicare Advantage for Veterans. Contact one of our agents to see if you’re eligible for one of these programs.

What Are The Costs

Your out-of-pocket costs depend on many variables, like:

  • Whether the Advantage plan has a monthly premium, some programs don’t
  • Whether the program has an annual deductible
  • Whether you follow plan rules, such as using the network providers
  • Copayments – how much you pay for each visit or service
  • Some advantage plans also cover all or a percentage of your Part B premium
  • The kind of healthcare services you need and how often you need them
  • The plan’s annual cap on your out-of-pocket costs for all healthcare services

Each Advantage plan determines what they charge for premiums, deductibles, and services.

Medicare Advantage HMO Plans

Private insurance companies offer Medicare Advantage plans, alternatives to Original Medicare (Part A and Part B). Medicare Advantage plans come in different types: HMOs, PPOs, SNPs, and PFFS. Each plan is different, so comparing your options is very important.

HMOs, which are Health Maintenance Organizations’ plans, provide coverage when you receive your care and treatment within their provider network. This means there is a list of healthcare service providers enrollees can visit. If you do not receive your care and services from one of the plan’s in-network providers, you will not receive coverage for your healthcare expenses. This is because Medicare Advantage HMO plans do not provide coverage for out-of-network services unless it’s for an emergency.

Plan Features

While some may not like that HMOs require their plan members to use their in-network providers to receive coverage, the services you receive cost less than if you were to have another plan, such as a PPO plan.

With HMOs, you will also be required to choose a primary care doctor within the plan’s network and obtain referrals from this primary care doctor to see a specialist.

Also, to enroll in an HMO plan, you must first be enrolled in Original Medicare.

HMO Plan Coverage

Like all Medicare Advantage plans, HMO plans will provide their plan members the same coverage they would receive if they just had Original Medicare. This includes coverage for inpatient and outpatient services.

However, HMO plans can also include additional benefits, such as:

  • Dental coverage
  • Vision coverage
  • Hearing coverage
  • Prescription drug coverage (most HMO plans will provide this)
  • Nutrition and wellness programs

Remember that your extra benefits depend on your area and the plan providers

Medicare Advantage PPO Plans

Unlike Medicare Advantage HMO plans, Preferred Provider Organization (PPO) plans offer more freedom. If you are enrolled in a PPO plan, you can receive healthcare services from out-of-network providers, though you will have more out-of-pocket costs if you do so. PPO plans allow you to receive medical services from any provider, though it costs less to stay in-network.

Features of PPO Plans

While not being required to receive your care within your plan’s provider network is one feature of a PPO plan, there are other features to note.

Under PPO plans, you do not have to get a referral before visiting a specialist. You can see both in-network and out-of-network specialists. You also don’t have to choose a primary care doctor like you would if you had an HMO plan. With PPO, if you do choose a primary care doctor, it can be either in-network or out-of-network.

When comparing your Medicare Advantage options, specifically HMO and PPO plans, noting the features of each plan will show you the key differences between the two. However, working with an agent from Jersey Medicare Solutions who specializes in Medicare can help you in the comparison process to make it much easier for you to find a plan that fits your needs best.

PPO Plan Coverage

Like all Medicare Advantage plans, PPO plans will provide their plan members the same coverage they would receive if they just had Original Medicare. This includes coverage for inpatient and outpatient services.

However, PPO plans can also include additional benefits, such as:

  • Dental coverage
  • Vision coverageHearing coverage
  • Prescription drug coverage (most PPO plans will provide this)
  • Gym memberships
  • Nutrition and wellness programs

Remember that your additional benefits depend on your area and the plan providers.

Medicare Advantage C-SNP

C-SNPs are Chronic Condition Special Needs Plans. These are a type of Medicare Advantage plan designed specifically for people who have specific chronic conditions. With one of these plans, you have the benefit of access to a network of healthcare professionals who can treat your disease.

C-SNP Coverage

Like other Medicare Advantage (Part C) plans, C-SNPs offer you the same covered services as the hospital and medical insurance under Original Medicare (Part A and Part B). A Medicare Advantage plan can also provide additional benefits such as coverage for dental, vision, hearing, or even gym memberships. Prescription drug coverage comes standard with all C-SNP plans, so you must pay only small copayments instead of the total price for your prescription medications.

Chronic Condition Special Needs Plans contract with a network of healthcare providers who can treat your chronic condition. This often includes specialists in the area of your state, which is one of the main draws of these plans. Under a typical Medicare Advantage plan, you may have had to pay more to see these specialists as they may have been outside the plan’s network.

In an emergency, you can seek treatment from any healthcare provider. If you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis, you can receive these treatments as needed. It would help if you were prepared to pay higher out-of-pocket costs for the care you receive outside your plan’s network.

With a Chronic Condition SNP, you need a primary care doctor or care coordinator who can help manage your healthcare. Having one of these professionals guide your care will ensure you receive the specialized treatments you need.

Qualifying Chronic Conditions For C-SNP Plans

To qualify for a New Jersey C-SNP, you must have a chronic condition defined by Medicare and the Center for Medicare and Medicaid Services (CMS).

The chronic conditions with C-SNP plans include:

  • Chronic alcohol and other drug dependence
  • Autoimmune disorders
  • Cancer, pre-cancer, or in-situ status
  • Cardiovascular discords
  • Chronic heart failure
  • Dementia
  • Diabetes mellitus
  • End-stage liver disease
  • End-stage renal disease (ESRD) requiring dialysis
  • Severe hematologic disorders
  • Chronic lung disorders
  • Chronic and disabling mental health conditions
  • Neurologic disorders
  • Stroke

There is also five grouped condition C-SNP plans for the following comorbid chronic conditions:

  • Diabetes mellitus and chronic heart failure
  • Chronic heart failure and cardiovascular disorders
  • Diabetes mellitus and cardiovascular disorders
  • Diabetes, Mellitus, chronic heart failure, and cardiovascular disorders
  • Stroke and cardiovascular disorders

Medicare Advantage D-SNP

Generally, SNPs are Special Needs Plans whose members meet specific criteria. Dual Eligible SNPs (D-SNPs) are a type of Medicare Advantage plan for people eligible for both Medicare and Medicaid. If you qualify for a D-SNP Plan, we can help you sign up for coverage that suits your needs.

D-SNP Coverage

Medicare Special Needs Plans are a Medicare Advantage option similar to an HMO or PPO. Like other Part C plans, these offer a choice of Original Medicare (Part A and Part B). You receive the same hospital and medical coverage as under Part A and Part B, as well as additional benefits offered by your particular plan. All Special Needs Plans provide prescription drug coverage.

Most SNPs contract with networks of healthcare providers. With D-SNPs, your network should be coordinated to choose providers that also accept Medicaid. Visiting these providers will save you money because your plan has negotiated lower rates for covered services. Seeing providers outside your plan’s network will result in higher out-of-pocket costs.

You do not need to worry about being covered in an emergency: you will be covered for emergency or urgent care services. This is also covered if you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis.

Your D-SNP will likely ask you to have a primary care doctor or care coordinator to help manage your healthcare. You will also need a referral from your doctor to see a specialist.

Qualifying For A D-SNP Plan

Enrolling in a D-SNP must be eligible for Medicare and Medicaid coverage. Different states vary in their requirements for which Medicaid programs you must participate in meeting the eligibility criteria for these Special Needs Plans.

To qualify for a Medicaid program in New Jersey, you must meet specific income and resource requirements. Your income and resources will determine which program you fall under. Suppose your income is higher than a program’s limits. In that case, you may be able to “spend down” your income with your medical expenses to meet the requirement (if your healthcare expenses reduce your payment to fit within the income limit).

There are several programs under Medicaid, including the following:

  • Full Medicaid (only)
  • Qualified Medicare Beneficiary without other Medicaid (QMB Only)
  • QMB Plus
  • Specified Low-income Medicare Beneficiary without other Medicaid (SLMB Only)
  • SLMB Plus
  • Qualifying Individual (QDWI)

Medicare Advantage PFFS Plans

PFFS Plans are one of many types of Medicare Advantage Plans offered by private insurance companies. We will look at the main advantages versus disadvantages to help you fully understand how PFFS plans work.

Medicare Basics

First, let’s review Original Medicare for transparency. The government offers original Medicare for individuals over 65 (or under 65 with specific disabilities or end-stage renal disease). Traditionally, two parts combine to give us Original Medicare as well as optional coverage to help people manage the rising cost of prescription medications:

  • Part A covers inpatient hospital costs
  • Part B covers outpatient medical expenses
  • Part D covers Prescription Drug Plans or PDPs

Medicare Advantage Private Fee-for-Service Plans (PFFS) are also known as “Part C” Medicare Plans.

Medicare Advantage PFFS Plans Explained

PFFS plans can be customized to your needs and budget. They provide the same coverage as Original Medicare and may offer extra benefits, such as vision and dental.

Maximum annual out-of-pocket expenses protect plan members if they need extensive medical care in one calendar year. In addition, PFFS plans cannot charge more than Original Medicare for many essential services, including chemotherapy, radiation, and dialysis.

Each PFFS plan predicates the amount paid to your healthcare provider versus what you will be responsible for on the day of your care. The monthly premium for a PFFS plan will vary among private insurers. You’ll continue to pay the Medicare Part B monthly premium ($170.10 in 2022) while enrolled in a PFFS plan.

Many PFFS plans have networks in which any physician in the network should treat any policyholder, even if it’s your first visit. As a plan member, you won’t be required to get referrals to see specialists, but you may want to discuss services with your physician — PFFS plans preset each service fee. This can help you avoid unnecessary out-of-pocket expenses.

PFFS plans typically cover prescription drugs but can be supplemented with a PDP (prescription drug plan) if needed.

If you need help with purchasing Medicare Advantage plans, contact our experienced Medicare advisors who will help you find a plan that best suits your budget and needs.

Table of Contents

Skip to content