Medicare Advantage Plans

Medicare Advantage Plans include benefits from Original Medicare Part A (hospital insurance), Part B (medical insurance), usually Part D (prescription drug coverage), and additional benefits that Original Medicare doesn’t cover. Medicare Advantage Plan insurer sets rules on how beneficiaries receive and pay for these benefits.

For Hospital and skilled nursing facility inpatient care, Medicare advantage plan coverage includes medically necessary outpatient services, such as:

• Doctor’s visits
• Ambulance services
• Emergency and urgent care
• Durable medical equipment (DME)
• Mental health care
• Prescription drugs that you cannot self-administer
• X-rays
• Laboratory tests

For Home health care, the Medicare Advantage plan covers Preventive services, such as:

• Vaccinations
• Cancer screenings
• Diabetes screenings
• Depression screenings

If Prescription drug coverage is included on your Medicare Advantage Plan, Additional benefits (depending on your plan) includes:

• Routine vision exams with allowance for glasses
• Routine dental exams
• Hearing exams with allowance for hearing aids
• Fitness and wellness programs and discounts
• Transportation to medically necessary care
• Over-the-counter (OTC) drugs

Medicare Advantage Plan Types in Utah

HMOs

HMOs require that you receive all services from in-network providers:

• Must have a primary care physician (PCP), referrals for specialists, and prior authorizations for treatments and some prescriptions.
• Drug coverage is included. You cannot purchase standalone drug coverage.
• if you stay in the network, you’ll have lower costs

PPOs

PPOs include a preferred network of providers. Here, you can choose doctors or hospitals of your choice from outside of the network for a higher cost.

• Choosing a primary care doctor or referrals for specialists is not needed
• Drug coverage is included.
• You cannot purchase stand-alone drug coverage.
• Higher premium and also out-of-network costs.

PFFS Plans

Primary care physicians or referrals for specialists are not required with the PFFS plan.

• Any Medicare-approved health care provider or facility is allowed as long as it accepts the plan’s payment terms and agrees to treat you.
• This may include drug coverage, or you can purchase a stand-alone drug plan.
• If you choose a provider that doesn’t agree to the plan’s terms, this may give you a higher cost.

SNPs

SNPs are designed for people with specific conditions and characteristics. This may include care coordination and targeted benefits tailored to meet specific needs

• PCP and referrals to specialists are needed
• Drug coverage is included.
• You can join an SNP at any time, as long as you’re eligible.

MSA (medical savings account) plans

High-deductible health plans with a medical savings account are compounded in these plans. Before your coverage starts paying, your deductible is the amount you pay for services covered. Your plan deposits money into the account, and you pay for healthcare using that money. There will be times that you may need to spend your own money until you meet your plan’s deductible.

The enrollment period for Medicare Advantage Plans in Utah.

You need to be enrolled in Medicare Part A and Part B if you want to sign up for a Utah Medicare Advantage Plan. It is important to note that you cannot be enrolled in Medigap. Seniors 65 and older and those with a qualifying disability can enroll. Disability typically qualifies if beneficiaries received at least 24 Social Security or Railroad Retirement Board (RRB) Disability Insurance payments. Those with End-Stage Renal Disease (ESRD) or amyotrophic lateral sclerosis (ALS) can also enroll for Medicare Advantage Plans.

Initial Coverage Election Period 

This is when you first become eligible, which includes the three months before your 65th birthday, the month of your birthday, and the three months following. This period will occur three months before or after your 25th month of receiving benefits if you have a disability.

Annual Election Period

This period runs from October 15 to December 7. Members can switch from Original Medicare to a Medicare Advantage Plan within this period. Beneficiaries can also switch plans during this period.

Open Enrollment Period

This period takes place between January 1 and March 31. During this period, members may switch between Medicare Advantage Plans or return to Original Medicare.

For unusual life events ( losing your job and health coverage) and moving out of your insurance carrier services area, Medicare provides special enrollment periods. 

Factors in Choosing Medicare Advantage Plan in Utah

Monthly premium

This is added to your Part B Premium. Whether you have access to your benefits or not, you pay. Members should have access to at least one zero-premium plan with drug coverage in their location.

Medical Provider network

Ensure that your doctors, hospitals, and pharmacies are in-network to lower costs.

Maximum Out-of-pocket 

This doesn’t include your premium, deductible, and drug costs, and this is the most you’ll be spending for Medicare-covered services as long as you follow your coverage rules for in and out-of-network coverage.

Cost Sharing 

Also known as Deductibles, coinsurance and copays are expenses applied when you access your benefits. Look at your coverage charges for doctor’s visits, services, treatments, and prescription drugs.

Drug formulary

Check if your drugs are on the coverage’s formulary. See also the cost each time you fill a prescription. Ask your doctor about a generic or alternative drug you may need.

Additional benefits

Look closely at which additional benefits are essential to you. Most coverage may charge extra premiums for comprehensive coverage and require you to utilize network providers.