Medicare Advantage (Medicare Part C) is an alternative way Medicare beneficiaries may be able to receive their Medicare Part A and Part B coverage.  Medicare Advantage plans are offered by private insurance companies that contract with Medicare to provide coverage that is at least as comprehensive as Original Medicare Part A (hospital insurance) and Part B (medical insurance). Because Medicare Advantage plans are offered locally, their availability in Utah (as in any state) may vary from one county to another.

How Medicare Advantage works in Utah

If you enroll in a Medicare Advantage plan in Utah, as in any state, you’ll receive your Original Medicare Part A and Part B benefits from a private insurance company that contracts with Medicare. Other than hospice care, which remains covered under Part A, the government requires Medicare Advantage plans to cover at least the same medical and hospitalization benefits as Original Medicare. Many Medicare Advantage plans offer more coverage than Original Medicare by means of lower deductibles and maximum out-of-pocket expense limits as well as extra benefits, like routine vision services and prescription drug coverage.

To enroll in a Medicare Advantage plan, you must have Original Medicare, Part A and Part B and live in the plan’s service area.  (In most cases if you have end-stage renal disease (ESRD) you might not be able to change coverage to a Medicare Advantage plan.)

You can sign up in a Medicare Advantage plan during your Initial Coverage Election Period.  Your Initial Coverage Election Period (ICEP) is when you’re first eligible to enroll into a Medicare Advantage plan. In most cases, it’s the seven-month period, which starts three months before the month in which you turn age 65, includes your birth month, and concludes three months after your birthday month.

You can also enroll in a Medicare Advantage plan in Utah (as in the other states), or switch to a different Medicare Advantage plan, during the Medicare Advantage and Prescription Drug Plan Annual Election Period, which runs from October 15 to December 7 each year. Your new coverage goes into effect on January 1 of the following year.

Under certain circumstances, you may qualify for a Special Election Period, when you can enroll in or switch Medicare Advantage plans. Those situations include, but aren’t limited to circumstances such as moving to a new residence outside your Medicare Advantage plan’s service area; losing your current employer-sponsored health coverage or experiencing changes in your current plan  that affect  your health benefits. Special Election Periods are timed to coincide with the event that triggers your loss or potential loss of health benefits and works to allow you to receive Medicare coverage.

If you’re enrolled in a Medicare Advantage plan in Utah but want to switch back to Original Medicare, Part A and Part B, you can do this during the Medicare Advantage Open Enrollment Period, which runs annually from January 1 to March 31 . You may be able enroll in a stand-alone Medicare Part D Prescription Drug Plan or switch Medicare Advantage plans during that period as well.

Types of Medicare Advantage plans in Utah

There are various kinds of Medicare Advantage plans in Utah, as in the rest of the United States. Here’s a look at the main types of plans:

A Health Maintenance Organization (HMO) plan is a type of Medicare Advantage plan that requires you to use doctors, health-care providers, and hospitals included in your plan’s network to receive benefits for covered services. A Medicare Advantage HMO plan usually will not pay for services you receive from a health-care provider who does not participate in the plan’s network unless you needed emergency care or received pre-approval from the plan to receive treatment outside the network. You may have to get a referral from your primary doctor to receive coverage for certain health services. An HMO Point-of-Service plan (HMO POS), on the other hand, is a more flexible option, allowing you to go out of network for some health services and receive benefits, but generally you pay higher out-of-pocket costs for these covered services than you would pay if you received the services from providers in the plan’s network.

If you prefer a Medicare Advantage plan with more flexibility, you may be able to choose a Preferred Provider Organization (PPO)* plan. In a Medicare Advantage PPO plan, you may choose doctors, health-care providers, and hospitals in or outside of your plan’s network.  Your out-of-pocket costs are typically lower when you receive covered services from providers in the plan’s network.

You may be able to select a Private Fee-for-Service (PFFS) plan reserves the right to decide how much it will pay for your doctor, health-care provider, and hospital visits, and also determines your share of each expense. Any provider you use must agree to accept the plan’s terms and conditions on a case-by-case scenario and agree to treat you. The PFFS plan may include a partial or full network of participating providers.  Keep in mind that not all providers accept this plan.  Make sure you check with the provider before receiving services

Another option may be Medicare Advantage Medical Savings Account (MSA) plan, which combines a high deductible with a savings account that you can use to pay for your health care expenses.

If you have specific health conditions, you may want to consider a Medicare Advantage Special Needs Plan (SNP). There are Medicare SNPs for people with certain chronic diseases, such as congestive heart failure or HIV/AIDS, for people who live in nursing homes, and for people who qualify for both Medicare and Medicaid. A Medicare SNP offers coverage tailored to certain circumstances that may require specialized care.

If you’re seeking both health and prescription drug coverage, you may want to see if  a Medicare Advantage Prescription Drug (MAPD) plan is available where you live in Utah.  These plans combine health and prescription drug coverage.  If one is not available where you live, you may still be able to enroll in a stand-alone Medicare Part D Prescription Drug Plan to complement your Medicare Advantage plan.

If you decide to enroll in a Medicare Advantage plan in Utah, or in any state, remember that you may have to continue paying your Medicare Part B premium in order to retain your health coverage.

Comparing Medicare Advantage plans available in Utah

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

The availability and cost of Medicare Advantage plans can vary depending on your county of residence, the insurance company offering the plan, and the benefit plan design.  You may find that some Medicare Advantage plans in Utah offer premiums as low as $0. In comparing the costs of Medicare Advantage plans available, it’s a good idea to consider other factors in addition to premiums, such as, copayments, coinsurance, and deductibles that you would pay out-of-pocket if you enrolled in the plan.

In addition, check to see if the Medicare Advantage plan has a network of participating health-care providers, and if you would be restricted to using the network to receive most of your plan’s benefits. And check to see if your doctors and preferred hospitals participate in the plan.

Finally remember that some Medicare Advantage plans may offer additional benefits beyond what is included in Original Medicare, Part A and Part B.  You’ll want to think about which coverage options are important to you, plus whether or not you want prescription drug coverage included in your Medicare Advantage plan.

With all these options available in Utah, you can see why it’s important to review and compare each plan to find the one best suited to your personal needs. To start comparing Medicare Advantage plans in Utah today, enter your zip code above for a customized list of plans available in your area. You can also enter your prescription drug needs to further refine your search and cost estimates.

For more information about Medicare in Utah, you can follow these links:

* 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.