If you’re a Medicare beneficiary living in Massachusetts, you may have the option to receive your Medicare Part A and Part B benefits through the alternative means of Medicare Advantage (Medicare Part C). Private insurance companies that contract with Medicare provide these benefits locally. Your choice of Medicare Advantage plans in Massachusetts depends upon where you live and which plans are available to you.

How Medicare Advantage works in Massachusetts

Unlike Original Medicare, which is administered by the federal government, private insurance companies approved by Medicare offer Medicare Advantage plans. In Massachusetts and the rest of the United States, the federal government requires Medicare Advantage plans to provide at least the same benefits as Original Medicare, Part A (hospital insurance) and Part B (medical insurance), with the exception that Part A continues to cover hospice care. Many Medicare Advantage plans in Massachusetts also offer additional coverage, such as fitness programs and/or prescription drug coverage.

To enroll in a Medicare Advantage plan in Massachusetts (as in all states), you must be enrolled in Original Medicare, Part A and Part B, and live within the plan’s service area. In most cases, you are ineligible to enroll in a Medicare Advantage plan if you have end-stage renal disease (ESRD or kidney failure) because Original Medicare has provisions for coverage of this condition and its treatment options.

If you’d like to sign up for a Medicare Advantage plan, you can enroll when you’re first eligible, during your Initial Coverage Election Period (ICEP). Usually, the Initial Coverage Election period is the same as your Initial Enrollment Period, which begins three months before you turn 65, includes your birthday month, and ends three months after that month.

If you missed your first chance to enroll in Medicare Advantage, you can still sign up during the Fall Open Enrollment Period, which runs from October 15 to December 7. You can also switch plans and make certain other coverage changes during this period. Your new coverage goes into effect on January 1 of the following year.

In some cases, you can enroll in or switch Medicare Advantage plans during a Special Election Period. These situations may include, but are not limited to: moving to a new address outside your plan’s service area, losing your current coverage, and experiencing changes in your current plan that affect your health benefits. Special Election Periods vary depending upon your personal circumstances and your ability to access the Medicare coverage to which you are entitled.

If you’re already enrolled in a Medicare Advantage plan in Massachusetts, but want to switch back to Original Medicare, Part A and Part B, you can make the change during the Medicare Advantage Open Enrollment Period , which runs from January 1 to March 31 each year. You can also add a stand-alone Medicare Part D Prescription Drug Plan during that period to go alongside your Original Medicare, if you dropped your Medicare Advantage plan.

Types of Medicare Advantage plans in Massachusetts

It’s a good idea to familiarize yourself with the various types of Medicare Advantage plans available prior to choosing a plan. Medicare Advantage in Massachusetts may include the following types of plans:

  • A Health Maintenance Organization (HMO) plan is a type of Medicare Advantage plan that generally requires you to visit doctors, health-care providers, and hospitals included in your plan’s network to receive benefits from the plan except in the instances of emergency care or medically necessary care that is authorized by the plan and not available within the plan’s network. Note that you may have to get a referral from your primary doctor or health provider to receive coverage for certain health services.
  • An HMO Point-of-Service plan is more flexible than a standard HMO plan, allowing you to sometimes go out of network for a number of health services, but generally at a higher out-of-pocket cost.
  • A Preferred Provider Organization (PPO)* offers even greater flexibility, allowing you to select doctors, health care providers, and hospitals outside of your plan’s network, but again at a higher out-of-pocket cost.
  • A Private Fee-for-Service (PFFS) plan may offer a partial or full network of providers, and sometimes does not involve any networks at all. It is important to check with the provider to see if they accept the plan because not all providers accept it.
  • A Medical Savings Account (MSA) plan combines a high deductible with a savings account that you can use to pay for your health-care expenses.
  • A Medicare Special Needs Plan (SNP) is for people with particular health needs, offering coverage tailored to suit their specific medical situations. There are Medicare SNPs for people with chronic conditions such as congestive heart failure or diabetes, those living in institutions (like nursing homes), and people who qualify for both Medicare and Medicaid.
  • A Medicare Advantage Prescription Drug (MAPD) plan combines health and prescription drug coverage into a single insurance plan.

If you decide to enroll in a Medicare Advantage plan, you continue paying your Medicare Part B premium in order to keep your health coverage.

Comparing Medicare Advantage plans available in Massachusetts

As a Medicare beneficiary in Massachusetts, you may find it useful to compare all Medicare Advantage plans available in your area.

The availability and costs of Medicare Advantage plans generally vary depending on where in Massachusetts you live and the plan details. Benefits and premiums may vary among Medicare Advantage plans. These differences may be reflected in the offerings available where you live. You may find that some Medicare Advantage plans offer premiums as low as $0. However, it may be wise to look beyond premiums alone, and consider benefit features such as deductibles, coinsurance and copayment amounts when evaluating your potential out-of-pocket costs to participate in the plan. Beyond the list of covered services, also consider whether the Medicare Advantage plan has a network of participating providers that includes the doctors and other health-care providers with whom you have a relationship.

See the following articles for further details about Medicare in Massachusetts:

*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.