There are many names for Medicare Advantage – Medicare “replacement” or Medicare “Part C” to name a few – but they all basically stand for the same thing. Medicare Advantage is a special type of health insurance policy which is closely linked to the federal Medicare program. These policies, provided by a private company, offer many of the health benefits you would normally get through federal Medicare, plus the option to add additional coverage and benefits. Medicare Advantage is just one of many ways in which you can supplement your Original Medicare coverage.

Federal Regulations for Medicare Advantage

By law, each Medicare Advantage policy must offer you the same benefits as Original Medicare Parts A and B. These laws protect consumers, since a Medicare Advantage effectively replaces your federal health benefits, from being sold inferior coverage. However, such scenarios are unlikely. If anything, you will end up with more coverage than when you started.

Medicare Advantage Enrollment In New Jersey

New Jersey seniors have a modest appreciation for Medicare Advantage policies. According to our data, only 21% of retired persons in the state are supplementing their Medicare benefits through Medicare Advantage. Of those, you can easily see which Advantage plans have the highest rankings among seniors:

Plan Type Enrollment Percentage
HMO Plans 59%
Local PPO Plans 13%
Special Needs Plans 11%
Regional PPO Plans 9%
Private Fee-For-Service Plans 5%
Other (Cost Plans, MSA’s, etc.) 3%

Plan Coverage & Cost

Are you male, or female? Are you a smoker, or have you ever been one? Do you exercise regularly? In what part of New Jersey do you live? These questions, and more, can play an important part in how your monthly premiums are calculated. Look below for some sample estimates:

Most Popular Medicare Advantage Plans in New Jersey

Finding the best performing Medicare Advantage program in New Jersey could be as simple as checking out Medicare’s Overall Star Rating report. This is an evaluation of all companies that offer goods or services related to Medicare. Medicare takes data it receives from these companies, plus survey results from customers, and assigns a performance rating based on stars. The more stars the better. For Medicare Advantage companies Medicare looks at how well screening and testing is used, how chronic illness is managed, customer experiences, complaints and changes in performance ratings, and customer service.

Helpful Medicare Advantage Tips & Tricks

Doctor/Provider Network Restrictions

Unfortunately, Medicare Advantage is not as widely accepted as Original Medicare. This is due to the provider network system which Advantage providers use in order to provide you with medical care. Some Plans, such as HMO plans, give you a very limited selection of doctors and hospitals to choose from, along with elevated restrictions for getting care. But these plans are typically more affordable than PPO or PFFS Medicare Advantage plans.

Where you generally need to get your care and services from for:

  • HMO Plans – If your Medicare Advantage plan is organized as an HMO, you will generally only be able to use the healthcare providers and facilities that are in the HMO network. Your HMO primary physician is responsible for referring you to other HMO resources should you need them. Some plans will offer a Point of Service option that allows you to see a provider outside the network for a price.
  • PPO Plans – PPOs also operate comprehensive networks of providers and facilities, but unlike HMOs, you can choose anyone you like provided they accept Medicare and your insurance plan. You do not need referrals to specialists. If you use out-of-network providers or resources be prepared for higher copays and deductibles.
  • PFFS Plans – Private Fee For Service (PFFS) plans have no restrictions on who you use providing they accept Medicare and the plan’s payment schedule. Not all will. Providers consider a PFFS plan’s payment terms for each service provided. Just because a healthcare provider accepts a PFFS plan’s payment terms for one treatment does not mean they will automatically accept all future payment terms for other service provided to the same patient. It is your responsibility to ensure the provider will accept your plan before receiving any services.
  • Special Needs Plans – If you are in a Special Needs Plan (SNP) the providers that you can see are usually limited to those that are in your plan’s group. These are specialists of the Medicare SNP network who focus on treating persons with conditions similar to your own.

Doctor/Providers List

Finding a doctor who accepts your Medicare Advantage plan:

  • HMO Plans – If you have joined an HMO, you don’t have to worry about finding a healthcare provider who accepts the plan. You can only use providers in the network. Your primary care doctor is responsible for referring you to other physicians or facilities and he or she is only going to send you to HMO network members.
  • PPO Plans – PPOs are a bit of a different story. Unlike HMOs, a PPO allows you to use providers both in and out of their network. Typically, they will offer an online directory of all network members showing name, specialty, location, a short bio, and some even offer patient ratings. If you already have doctors, but they are not in the network, call and ask if they will accept the insurance plan you are considering. If they will, you can use them, just expect to pay a higher copay.
  • PFFS Plans – Some PFFS plans contract with networks of providers. If yours does, there will be a directory of those physicians and facilities. If not, you’re free to use anyone who accepts Medicare and the plan’s payment terms. The catch is some providers will accept the plan for one procedure but not for another. It is up to you to confirm coverage before receiving any treatment.
  • Special Needs Plans – Like an HMO, your SNP plan will limit you to providers in your group so finding someone is not a concern. All the providers in your group are part of the Medicare SNP Network.

Sometimes, finding a doctor who accepts your Medicare Advantage plan can seem daunting. But in reality, finding a provider is as easy as finding a doctor who accepts Medicare. Most plans have tools similar to Medicare’s physician search tool that allow you to quickly identify resources near you.

Drug, Vision and Dental Coverage

Original Medicare has eye care benefits limited to exams for diabetic retinopathy and age related macular degeneration. Many Medicare Advantage plans offer additional eye care coverages for their members. Generally, these include an annual exam, lenses, contacts, and glasses. Optical shops that participate in this plan often offer members with discounts for other services.

Dental care is another area that Original Medicare does not provide for. Again, many Medicare Advantages offer dental services but they can vary widely. At a minimum they usually include an annual exam including the cost of x-rays and cleaning. Others may offer fillings, periodontal care and other services. Refer to your plan’s directory for participating dental offices.

Enrollment Options & Best Time To Enroll

The best time to enroll in Medicare Advantage is right after you turn 65, within your Initial Enrollment Period window. Outside of this six month window, it can become increasingly difficult to get quality coverage at an affordable price. This can become an even more difficult challenge if you are plagued by any sort of chronic illness (such as End Stage Renal Disease) or other serious pre-existing condition. However, there are options. Your state department of insurance will have more information, as well as your local insurance agent. You can also visit our Medicare Advantage Enrollment Options page for additional info.

  • Initial Enrollment Period: Within your first 6 months of Medicare enrollment, you can enroll in a Medicare Advantage policy.
  • Annual Enrollment Period (AEP): From October 15th through December 7th each year, you are free to change or cancel your Medicare Advantage and part D drug plan.
  • Special Enrollment Period (SEP): Any sort of special circumstance in which you may need to change or get new coverage outside of a regular enrollment period, such as moving out of your service area, losing your employer/plan coverage, or your provider ceasing coverage in your area.

What Medicare Advantage Plan Is Best For Me?

The best New Jersey Medicare Advantage plan for you is one that offers the providers and facilities that you trust and has deductibles and co-pays that you can afford. If a plan offers Part D drug coverage, you want to ensure that the pharmacy has your medications. Only you can decide what the plan is for your specific situation. The perfect plan is out there but you have to take the time to determine just what you need before you can find it.

Premiums are always a major concern when making a decision but it gets tricky with Medicare Advantage plans. Many have zero-premium plans. If you qualify for one of these, then pay special attention to copays and deductibles. Don’t forget to take into consideration the reputation and financial stability of the company as well as how long it has been serving your area. Once you’re ready to make a decision, make it quickly – because your enrollment period may be expiring soon!

by Lindsay Malzone, Lindsay Malzone is the Medicare expert for She's been contributing to many well-known publications as an industry expert since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.