If you’re a Medicare beneficiary in Ohio, a Medicare Advantage plan can provide benefits beyond standard Original Medicare coverage. The specific plans available to you will depend on the part of Ohio you live in.
How Medicare Advantage works in Ohio
The Medicare Advantage (Part C) program in Ohio works the same way as in the rest of the country. Also known as Medicare Part C, the Medicare Advantage program offers an alternative way to get your Original Medicare benefits (through private insurance companies that contract with Medicare). While Original Medicare is administered by the federal government, your insurance company coordinates your care under Medicare Part C.
Medicare Advantage is simply another way to get your Original Medicare coverage – this means Medicare Part A (hospital insurance) and Part B (medical insurance). However, hospice care is still covered directly through Medicare Part A instead of through a Medicare Advantage plan. Many plans go beyond Part A and Part B, offering benefits that Original Medicare doesn’t cover, such as routine vision, routine dental, and prescription drug benefits.
Eligibility for Medicare Advantage is the same in all states, including Ohio. To sign up for a Medicare Advantage plan, you must:
- Have (or be eligible for) Medicare Part A and Part B.
- Permanently reside within the service area covered by the plan you’re signing up for.
- Not have end-stage renal disease (ESRD), in many cases. If you have ESRD, you might qualify for a Medicare Special Needs Plan.
Ohio beneficiaries who meet eligibility requirements can enroll in a Medicare Advantage plan or make changes to their coverage during the following periods:
- Initial Coverage Election Period: This is the period when you’re first eligible to enroll in a Medicare Advantage plan. It starts three months before you’re eligible for Original Medicare, . Learn more about the Initial Enrollment Period for Original Medicare.
- Fall Open Enrollment Period:Also called the Annual Election Period, this period runs from October 15 to December 7 every year. During the Annual Election Period, you can switch to Medicare Advantage, make changes to your prescription drug coverage, change Medicare Advantage plans, change Medicare Prescription Drug Plans, or disenroll from Medicare Advantage and go back to Original Medicare.
- Medicare Advantage Open Enrollment Period:This period runs from January 1 to March 31 each year. You can switch from one Medicare Advantage plan to another or drop your Medicare Advantage plan and return to Original Medicare. You’ll be able to join a stand-alone Medicare prescription drug plan if you drop your Medicare Advantage plan.
- Special Election Period: If you qualify for a Special Election Period, you can enroll in a Medicare Advantage plan or make coverage changes outside of the regular enrollment periods. Only certain situations qualify, such as moving out of your plan’s service area.
Types of Medicare Advantage plans in Ohio
There are several different types of Medicare Advantage plans. Not every plan may be available in your part of Ohio.
Here’s an overview of the some types of Medicare Advantage plans.
- Health Maintenance Organization (HMO): HMOs require you to use doctors in the plan’s network. You will have a primary care doctor and may need a referral to see a specialist.
- Preferred Provider Organization* (PPO): PPOs allow you to see out-of-network providers, but you’ll have lower costs if you use doctors in the plan’s preferred network. You won’t need a referral to see a specialist, and you are not required to have a primary care physician.
- Health Maintenance Organization Point-of-Service (POS): HMO-POS plans have features of HMO and PPO plans. You’ll have a primary care doctor, like an HMO, but you’ll also be allowed to pay more to see an out-of-network provider. HMO-POS plans may not require referrals if you need to see a specialist.
- Private Fee-for-Service (PFFS): Some Private Fee-for-Service plans don’t have provider networks, and let you use any provider that will accept the plan’s payment conditions. Providers contract with your Private Fee-for-Service plan and treat you on a case-by-case scenario, so you’ll need to verify that the provider takes your plan on each visit. Other PFFS plans do have provider networks, and you may pay more if you see out-of-network doctors. You’ll usually only pay the plan’s cost-sharing requirements (which may vary among plans), but some providers can charge up to 15% above the Medicare-approved amount.
- Special Needs Plan (SNP): Special Needs Plan membership is limited to people who meet certain eligibility criteria. There are three kinds of Medicare Special Needs Plans, each targeting a certain group, including people who have specific medical conditions, live in an institution, or receive Medicaid benefits. Every Special Needs Plan provides prescription drug benefits.
- Medicare Savings Account (MSA): This is a high-deductible Medicare Advantage plan that includes a medical savings account. The Medicare Savings Account plan deposits money into a savings account that you can use to pay for health costs without being taxed. You spend this money on Medicare covered health-care costs, and the amount you spend counts toward your deductible. However, your plan won’t pay for Medicare covered services until you reach the deductible. Medicare Savings Account plans don’t include prescription drug coverage.
Most Medicare Advantage plans include prescription drug benefits. Medicare Advantage Prescription Drug plans provide your Medicare Part A, Part B, and Part D (prescription drug) benefits under a single plan. You need to continue paying your Part B premium, along with any premium the Medicare Advantage plan may charge.
In most cases, you can’t enroll in both a Medicare Advantage plan and a stand-alone Medicare Prescription Drug Plan. If you’re enrolled in a certain type of Medicare Advantage plan that doesn’t include this coverage, such as a Medicare Savings Account plan or a Private Fee-for-Service plan that doesn’t come with prescription drug coverage, you may be able to enroll in a stand-alone Medicare Part D Prescription Drug Plan.
Comparing Medicare Advantage plans available in Ohio
Considering all the different types of Medicare Advantage plans, along with the fact that costs and benefits vary, you can see why it may be important to carefully review all of your available options. To start comparing Medicare Advantage plans in Ohio, just enter your zip code where indicated on this page to search for plans in your service area.
Some factors that may affect your choice of Medicare plan might include your current and future health needs, budget, provider choice, and whether you take prescription medications. If it’s important that you keep seeing a particular doctor, check that the provider is in the plan’s network. If you take prescription drugs, verify that the plan you sign up for covers all of your prescriptions, or you could end up paying a lot more out-of-pocket. A plan’s formulary (list of covered prescription drugs) may change at any time. You will receive notice from your plan when necessary. Remember that regardless of the Medicare plan you go with, you’ll have to keep paying the Part B premium.
You can also view the following page for more information on other types of Medicare coverage in Ohio:
*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.