Introduction to Medicare Part C in Illinois (Medicare Advantage)

Are you worried about how much you might end up paying in out-of-pocket medical bills if you don’t get your Medicare gaps covered? There are plenty of affordable Medicare supplement insurance policies which can help protect you from coverage gaps, and give you peace of mind. Medicare Part C (a.k.a. Medicare Advantage) is one such policy. In essence, it replaces your federal Medicare benefits with a private health insurance policy. It can also provide additional coverage to protect you from gaps, and help you acquire ancillary benefits under the same policy.

Federal Regulations for Medicare Advantage

Because a Medicare Advantage policy replaces your federal health benefits, there are regulations in place to protect you from private insurance companies who might otherwise take advantage of or exploit the process. By law, you must receive the basic health coverage offered by Medicare Parts A and B through Medicare Advantage. It is highly likely, however, that you will receive many more benefits beyond that.

Medicare Advantage Enrollment In Illinois

Thousands of Illinois seniors are signed up for the Federal Medicare program. Of those, 21% of Medicare recipients are getting their benefits through a Medicare Advantage plan. The other 79% may prefer Medigap insurance or have an employer plan.

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

Below, we have another chart which shows estimated costs for Medicare Advantage plans in your general area. Keep in mind, however, that these are only estimates. Additional factors, such as your age, zip code, and health status, will significantly influence your quoted rate.

Most Popular Medicare Advantage Plans in Illinois

Our Medicare Plan rankings work fairly similarly to other 5-star review rating systems. The more stars a plan earns, the better it will be for you. Plans and providers earn more stars if they excel at customer satisfaction, chronic condition management, and show an overall competence in helping you manage your healthcare needs. The fewer the stars they receive, the less of a value that particular plan will likely be.

Doctor/Provider Network Restrictions

One reason for the low number of Medicare Advantage enrollees in Illinois might have something to do with network restrictions. If you travel often, or if you don’t have access to a large city, it can be difficult to get access to the medical care that you need. Also, don’t forget that your insurance company could change the rules and regulations of your Network at any time. You’ll have to be prepared for unexpected rule changes.

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

  • HMO Plans – HMO plans tend to have very restrictive networks in order to keep costs affordable. You will likely see your claim from an out-of-network doctor or hospital rejected unless the claim is for emergency care, out-of-area urgent care, or out-of-area dialysis treatment. The only other exception is with a point-of-service HMO plan. POS plans allow you to go outside of your HMO network if you have a very specific reason for doing so; but this care is usually much more expensive than going in-network.
  • PPO Plans – PPO plans have a preferred network of providers they would like you to patronize, but you can still get your claims paid out if you get care from doctors and hospitals which are out of your network. These out-of-network facilities will usually cost more, and PPO plans are usually associated with higher monthly premiums. But for some seniors, having that level of flexibility and freedom is worth it.
  • PFFS Plans – PFFS plans are slightly different from PPO plans in that you still have the option to go out of network, but the doctor or facility you choose can elect to refuse your insurance and force you to pay out-of-pocket instead. Otherwise, similar rules about in- and out-of-network doctors/facilities apply.
  • Special Needs Plans – Special Needs Plans have networks which are tailored to cater to a specific medical condition that the policyholder suffers from. Going out of network is discouraged because the specific type of care you get could be compromised or prohibitively expensive. Aside from that, its rules for going out of network are very similar to those of an HMO, especially with regard to End Stage Renal Disease dialysis treatment.

Doctor/Providers List

Finding a doctor who accepts your Medicare Advantage plan:

  • HMO Plans – Identical rules exist for for Medicare Advantage HMO plans, too. As with a regular Medicare HMO plan, you will be limited to in-network doctors with the exception of certain emergency or urgent care situations. Going out of network could result in getting your claim rejected.
  • PPO Plans – Whether you have Medicare or Medicare Advantage, the same rules apply for either plan if that plan includes a PPO network. You can save money by getting care from preferred providers. Going outside of your preferred provider network may result in higher medical expenses.
  • PFFS Plans – PFFS plans are also no different under Medicare Advantage than they would be under any other Medicare insurance plan. If your chosen doctor or facility refuses your insurance, you’ll either have to pay out-of-pocket or get care somewhere else. But you are not necessarily limited to the network of preferred providers which are included in your PFFS plan.
  • Special Needs Plans – In addition to being cost effective, SNPs have the restricted networks that they do because your insurance company wants to make sure you get competent care from doctors and facilities which specialize in providing for your specific medical needs. Going out of network for anything other than emergency or urgent care, including ESRD dialysis, could get your claim rejected.

It’s a good idea to search the Medicare.gov database for your current doctors, hospitals, urgent care facilities, and other people/places where are you currently get regular medical care from. It’ll help you make sure you choose a plan were you can get the best possible care.

Drug, Vision and Dental Coverage

Of those seniors who are a part of a Medicare Advantage plan in Illinois, convenience might be a favorable reason. Of all the available Medicare supplement insurance plans, Medicare Advantage has the unique ability to bundle all the coverage you need into a single plan. This includes basic Medicare benefits, benefits for coverage gaps, Prescription drug (Medicare Part D) benefits, and optional coverage, such as dental or vision.

  • Vision coverage is an optional component of many Medicare Advantage plans. If you choose to purchase vision coverage, you will have to consult with your plan to figure out If you have a limited network of optometrists to choose from and who you can see.
  • Dental coverage is another optional component which is commonly offered with Medicare Advantage. You don’t have to purchase dental coverage – but if you do, make sure to go over that part of your policy with your provider so that you know which dentists you can and cannot see, assuming you have a limited network to choose from.

Enrollment Options & Best Time To Enroll

Enrolling early in a Medicare Advantage plan while you are still in good health is the best way to get the most affordable rate. The longer you wait, and/or the worse your health is, the more difficult it will be for you to get covered. This is especially true if you have ESRD (End Stage Renal Disease), or a similarly devastating health condition. Finding coverage isn’t impossible, however; simply talk to your local insurance agent, or reach out to your state department of insurance to learn about your options. Our Medicare Advantage Enrollment options page has some helpful info for you, too.

  • Initial Enrollment Period: For best results, try to enroll in a Medicare Advantage plan within your first 6 months of Medicare enrollment.
  • Annual Enrollment Period (AEP): You have the option of changing or cancelling your Medicare Advantage and Part D drug plan between October 15th and December 7th every year.
  • Special Enrollment Period (SEP): If you lose your employer plan coverage, move out of your coverage area, or lose coverage from your provider, you could qualify for an SEP.

What Medicare Advantage Plan Is Best For Me?

Choosing a Medicare Advantage plan is complicated. You have to do your best to guess what sort of medical care you will need in the future, along with the care you are currently receiving. Once you have a good idea of what your medical needs might be in the future, only then can you start shopping around for the right plan. Choosing the right plan also involves choosing a financially stable company with a strong history of customer care and service.

Medicare Advantage enrollment periods, like most things Medicare-related, are unfortunately limited. You don’t have much time to choose a plan in the first place – let alone time to pick a new, different plan if you change your mind. It’s a very big decision that you have to make with a limited amount of time to do it in. But you can make it easy on yourself by comparison shopping and getting fast, accurate quotes from providers near you.

Sources:

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