In Vermont, an alternative way for Medicare beneficiaries to obtain the benefits of Original Medicare Part A and Part B is through a Medicare Advantage plan (Part C). The same is true in other states. Private insurance companies contract with Medicare to offer Medicare Advantage plans locally.  If you decide to receive your Medicare coverage from a Medicare Advantage plan, you may be able to enroll in a plan that is available where you live.

How Medicare Advantage works in Vermont

In Vermont and throughout the United States, the federal government requires Medicare Advantage plans to offer at least the same level of benefits as Original Medicare Part A (hospital insurance) and Part B (medical insurance). With the exception of hospice care, which continues to be covered under Part A, you receive all of your Medicare benefits from the private insurance company that offers the Medicare Advantage plan in which you choose to enroll.  Some Medicare Advantage plans offer lower deductibles and copayments that may further reduce their members’ out-of-pocket expenses for Medicare covered health services; some plans even offer extra benefits, like wellness programs and prescription drug coverage, allowing beneficiaries to have more comprehensive coverage than under Original Medicare.

If a Medicare Advantage plan is of interest to you, the eligibility criteria for enrollment are important considerations. First, you must have Medicare Part A and Part B.  Second, you must live in the service area of the Medicare Advantage plan you choose. However, in most cases you are not eligible to enroll in a Medicare Advantage plan if you have end-stage renal disease, a condition which Original Medicare typically covers.

You can sign up with a Medicare Advantage plan during your Initial Coverage Election Period (ICEP), usually when you’re first eligible for Medicare. This time period often occurs when you are first eligible for Medicare Part A and Part B, also known as the Initial Enrollment Period, which for most people begins three months before the month you reach age 65, includes your birthday month, and ends three months after your birthday month.

If you didn’t sign up for a Medicare Advantage plan during the Initial Coverage Election Period, or if you want to switch to a different Medicare Advantage plan, you can do so during the Medicare Advantage and Prescription Drug Plan Fall Open Enrollment season, which runs from October 15 to December 7 each year.  Your new coverage goes into effect on January 1 of the following year.

In some situations, you might qualify for a Special Election Period. These situations include, but are not limited to: moving to a new address where your Medicare Advantage plan isn’t available; losing your current coverage; or experiencing changes in your current plan that affect your health benefits. The timing of Special Election Periods is not standardized like the enrollment periods discussed above; instead, a Special Election Period occurs when your circumstances change, usually when you have a life-changing event or a change in your health coverage that could jeopardize your receiving Medicare benefits to which you are entitled.

Finally, if you’re already enrolled in a Medicare Advantage plan in Vermont (as in any state), but want to switch back to Original Medicare (Part A and Part B), you can make this change during the Medicare Advantage Open Enrollment Period which runs January 1 through March 31 each year. The Medicare Advantage and  prescription drug plan Annual Enrollment Period  runs from October 15 through December 7 each year.

Types of Medicare Advantage plans in Vermont

Here’s a quick look at the various types of Medicare Advantage plans, but please remember not every type of plan is necessarily available in every part of Vermont.

  • Health Maintenance Organization (HMO):  To receive coverage an HMO plan requires you to visit doctors, health-care providers, and hospitals included in your plan’s network, except in emergency situations or when approved by the plan. You may also need to get a referral from your primary doctor to receive coverage for certain health services.
  • HMO Point-of-Service: An HMO-POS plan is a slightly more flexible option that an HMO, allowing you to go out of network for most health services, but generally at a higher out-of-pocket cost than if you received care from a provider participating in the plan’s network.
  • Preferred Provider Organization (PPO)*: A PPO plan offers great flexibility, allowing you to choose doctors, health care providers, and hospitals outside of your plan’s network, but usually at a higher out-of-pocket cost for covered services than you would pay if you used a provider in the plan’s network. .
  • Private Fee-for-Service (PFFS): A Private Fee-for-Service plan may offer a partial or full network of providers. This type of plan decides how much it will pay for covered services provided by your doctor, health-care provider, or hospital visits and how much you will pay. Keep in mind that not all providers accept this plan, make sure you check with the provider before receiving services
  • Medical Savings Account (MSA): A Medical Savings Account plan combines a high deductible with a savings account that you can use to pay for your health care expenses.
  • Medicare Special Needs Plan (SNP): Designed for Medicare beneficiaries with certain conditions, a Medicare Special Needs plan offers coverage tailored to suit those specific situations. There are Medicare SNPs for people with chronic health conditions, those who are eligible for both Medicare and Medicaid, and for people who are living in an institution, such as a nursing home.
  • Many Medicare Advantage plans include prescription drug coverage. Called a Medicare Advantage Prescription Drug (MAPD) plan, this kind of plan combines health and prescription drug coverage into a single insurance plan.

If you sign up for a Medicare Advantage plan, you continue paying your Medicare Part B premium in addition to any premium the plan may charge.

Comparing Medicare Advantage plans available in Vermont

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

The availability and costs of Medicare Advantage plans generally depend on your county of residence, the insurance company offering the Medicare Advantage plan, and the plan’s specific benefit details. You may find that some Medicare Advantage plans in Vermont offer premiums as low as $0, but you should also consider the plan’s other costs such as copayments and deductibles. (Keep in mind that you continue to pay your monthly Medicare Part B premium, no matter which Medicare Advantage plan you choose.)  Some further considerations to keep in mind when selecting a Medicare Advantage plan:

  • Do you need prescription drug coverage? If so, make sure the plan you choose is a Medicare Advantage Prescription Drug plan.  Also, check the plan’s formulary, or list of covered drugs, to see if your medications are included in the formulary. Note, a plan’s formulary may change at any time. You will receive notice from your plan when necessary.
  • Does the Medicare Advantage plan have a network of participating providers?  If so, check to see if your doctors, your other health-care professionals, and your preferred hospitals participate.  Your out-of-pocket expenses for care may be higher if your providers do not participate in the plan’s network.
  • What kinds of extra benefits are you interested in? Some Medicare Advantage plans may offer additional coverage beyond what is included in Original Medicare, Part A and Part B, so compare the plans available in your area to see which ones may include benefits that would be valuable to you.

With all these options, you can see why it’s important to compare Medicare Advantage plans to find one that offers benefits and costs suited to your personal health and budget requirements.

To get more information about Medicare in Vermont, you can review the following resources:

* 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.