Medicare Advantage (Medicare Part C) is an alternative way for those enrolled in Original Medicare, Part A and Part B, to get these benefits. Like residents of other states, New Jersey residents enrolled in Medicare Advantage are covered through their individual health plans and not directly through Medicare.
Medicare Advantage plans are available from private, Medicare-approved insurance companies, and are required to offer at least the same benefits as Original Medicare, except for hospice care, which is still covered under Medicare Part A.
How Medicare Advantage works in New Jersey
Original Medicare consists of Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). If you’re seeking additional benefits that aren’t available under Original Medicare, you may want to consider signing up for a Medicare Advantage plan in New Jersey. Medicare Advantage plans often include extra benefits like prescription drug coverage and routine dental, hearing, and vision services.
You can sign up for a New Jersey Medicare Advantage plan if you:
- Have both Part A and Part B
- Live in the service area of the plan you want to enroll in
- Don’t have end-stage renal disease (ESRD). There are exceptions, so if you have ESRD and want to sign up for a Medicare Advantage plan, you can ask Medicare about exceptions; the contact information is at the end of this article. You also may be able to get a Medicare Special Needs Plan (described later in this article).
Your first opportunity to enroll in a Medicare Advantage plan is during your Initial Coverage Election Period (ICEP):
- If you sign up for Medicare Part A and Part B when you’re first eligible for Medicare, you can enroll in Medicare Advantage at this time; your ICEP is a seven-month period that starts three months before the month where you turn 65, runs through your birth month, and continues for the three months after that.
- If you delay enrollment in Medicare Part B (for example, if you’re covered through employment), your ICEP is the three-month period before your Part B start date. For example, if you enrolled in Part B during the General Enrollment Period (January 1 to March 31), your Part B start date would be July 1, so your ICEP would be April 1 to June 30.
Another opportunity to sign up for a Medicare Advantage plan is during the Annual Election Period, also called the “Open Enrollment Period for Medicare Advantage and Medicare prescription drug coverage,” which runs from October 15 to December 7 each year. If you’re already enrolled in a Medicare Advantage plan and wish to switch plans, you can make the change during the Annual Election Period. Your new coverage begins on January 1 of the following year if you enroll in, or switch, Medicare Advantage plans during this period.
Sometimes, circumstances may effectively force you to change Medicare plans. Examples of these events include moving to a new address, losing your current coverage, qualifying for other coverage, or changes in your current plan that affect your health benefits. If you find that you have to change plans, you may qualify for a Special Election Period; call your plan or contact Medicare and ask for assistance (contact information is at the bottom of this page).
If you’re enrolled in a Medicare Advantage plan in New Jersey and decide to switch back to Original Medicare, Part A and Part B, you’re allowed to do so during the Medicare Advantage Open Enrollment Period, which runs from January 1 to March 31 each year. Original Medicare includes only very limited prescription drug coverage, so you can add an optional stand-alone Medicare Prescription Drug Plan (Part D) during this period. You also can switch Medicare Advantage plans during this period.
Types of Medicare Advantage plans in New Jersey
Medicare Advantage plan options vary in New Jersey, and they include, among others: Health Maintenance Organizations (HMO) plans, Preferred Provider Organization (PPO) plans, Special Needs Plans (SNPs), Private Fee-for-Service (PFFS) plans, and Medical Savings Account (MSA) plans.
- Under a Medicare Advantage Health Maintenance Organization (HMO) plan, you’re usually limited to doctors, health care providers, and hospitals in the health plan’s network. Also be aware that you may need a referral from your primary doctor to receive coverage for a number of health services. If you prefer to have a more flexible health plan, meaning one that allows you to go out of network (often paying higher costs) for various health services, you can choose an HMO Point-of-Service (HMO-POS) plan.
- Another option is a Medicare Advantage Preferred Provider Organization* (PPO) plan. This kind of health plan lets you choose your own doctors, health care providers, and hospitals, but you may end up having more out-of-pocket expenses by choosing this type of plan.
- Medicare Advantage beneficiaries in New Jersey with special health needs can apply for a Medicare Special Needs Plan (SNP). This type of Medicare Advantage insurance is geared to patients with specific health conditions, those living in an institution such as a nursing home, or people who are eligible for both Medicaid and Medicare. These plans are tailored to cover the particular needs of those beneficiaries. For example, there are some SNPs for patients with end-stage renal disease (ESRD) and others for those suffering from congestive heart failure.
- Under a Medicare Private Fee-for-Service (PFFS) plan, the health plan itself decides how much it will pay for your doctor, health care provider, and hospital visits, while also determining the beneficiary’s share for each payment. These plans generally allow you to see any provider that will accept the plan’s terms and conditions and agree to treat you; you’ll have to find providers that will contract with the plan on a case-by-case basis.
- Another choice for New Jersey Medicare beneficiaries is a Medical Savings Account (MSA) plan. These plans combine a high deductible with a savings account; you use the money in the account to pay for health care expenses.
You may decide you need prescription drug coverage with your health insurance. If so, you can select a Medicare Advantage plan in New Jersey that includes such coverage, as long as you live within the plan’s service area and meet other criteria listed above. These insurance plans are known as Medicare Advantage Prescription Drug plans, and they combine health and prescription drug coverage into a single plan. Most Medicare Advantage plans include this coverage, but check the plan’s policy before you sign up to make sure it covers your medications if you want this benefit.
Comparing Medicare Advantage plans in New Jersey
Medicare Advantage plans in New Jersey may have different extra benefits and details depending on the insurance companies that offer these plans. In addition, these details may change on a yearly basis, so it’s always a good idea to keep up with any policy changes and how they may affect your specific health needs
Besides the benefit details, the availability and costs of Medicare Advantage plans also vary, depending on where you live and on what companies offer the plans. Some plans may offer premiums as low as $0, but do keep in mind that you must continue paying your Medicare Part B premium, no matter which Medicare Advantage plan you choose.
You also need to decide whether or not you want prescription drug coverage with your Medicare Advantage policy, and figure out whether a plan you’re considering covers the medications you take and the other benefits you may need, such as dental services. (A plan’s formulary – its list of covered prescription drugs – may change at any time. You will receive notice from your plan when necessary).
With all these options, you can see why it can be important to compare plans with the benefits and costs so you can find one that may be suited to your specific health needs. To start comparing plans or learn more about Medicare Advantage, just enter your zip code in the form on this page.
Would you like to explore more Medicare coverage options? Read about Medicare Supplement (Medigap) plans in New Jersey.
*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 the plan will cover an out-of-network service, you or your provider are encouraged to ask for a pre-service organization determination before you receive the service. Please call the plan’s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.