Do Medicare Advantage Plans Vary by State?

Original Medicare is the only coverage that doesn't change from state to state. Medigap, Medicare Advantage, and Part D prescription drug plans are all sold privately and can vary depending on the state. Generally, larger states tend to have more plan options available than less populated states. Medigap plans, however, offer the same benefits in most states. In general, plans in all states must follow the same rules.

For example, all Medicare Advantage plans must cover the same services as original Medicare. Medicare uses a star rating system for Medicare Advantage and Part D plans, and the availability of high-quality plans is not the same in all states. Medicare Part A and Part B have standardized costs that are the same in all states. In 117 counties, representing 5 percent of the Medicare population, more than 60% of all Medicare beneficiaries are enrolled in Medicare Advantage plans or cost plans. Many of these counties are centered around large urban areas, such as Monroe County, New York (69%), which includes Rochester, and Allegheny County, PA (63%), which includes Pittsburgh.

By contrast, in 508 counties, which account for 3 percent of Medicare beneficiaries, no more than 10 percent of beneficiaries are enrolled in private Medicare plans; many of these low-penetration counties are located in rural areas of the country. Some urban areas, such as the City of Baltimore (20%) and Cook County, IL (Chicago, 28%) have low Medicare Advantage enrollment compared to the national average (39%). More than three million Medicare beneficiaries are enrolled in special needs plans (SNPs). SNPs restrict enrollment to specific types of beneficiaries with significant or relatively specialized care needs. Most SNP enrollees (86%) are in plans for beneficiaries with dual Medicare and Medicaid entitlement (D-SNP), another 11 percent of members are in plans for people with chronic conditions or severe disabling conditions (C-SNP), and 3 percent are in plans for beneficiaries who require a nursing home or institution level of care (i-SNP).In nine states, the District of Columbia and Puerto Rico, SNP enrollment comprises at least one-fifth of Medicare Advantage enrollment (55% in DC, 48% in PR, 23% in SC, 23% in NY, 21% in AR, 21% in GA, 21% in MS, 20% in AZ, 20% in FL, 20% in LA, and 20% in TN).

And while 14% of Medicare beneficiaries are under the age of 65 and are eligible for Medicare due to disability (including ALS and kidney failure), federal regulations do not guarantee access to Medigap plans for members under the age of 65. Unlike original Medicare, most Medicare Advantage plans also have a network that you'll need to stay within to get coverage - especially if your plan is an HMO. Publication enrollment counts for companies operating in the Medicare Advantage marketplace - such as company financial statements - may differ from KFF estimates due to the inclusion or exclusion of certain types of plans like SNPs or employer plans. Unlike Medicare Advantage plans, traditional Medicare generally does not require prior authorization for services and does not require step therapy for Part B drugs. Every year, the Centers for Medicaid Services & Medicare rates all Medicare Advantage plans on a five-star scale based on several quality indicators. Beneficiaries can have a Medicare Advantage Prescription Drug Plan (MAPD), an Independent Part D Plan (PDP), or neither - but they cannot have both.

You buy them in addition to your original Medicare coverage; the plans that are available to you will depend on where you live. Some older adults may live in an area with numerous affordable high-quality plan options while others may be left with high-cost low-selection options. Some states have implemented laws that make it easier for seniors to switch from one Medigap plan to another and for people under 65 to enroll in Medigap plans. Massachusetts has a two-month period each year (February to March) during which Medigap plans are guaranteed to be issued. Read up on additional Medicare cost guidelines to learn more about how they will affect you. When Medicare Advantage members require hospitalization many Medicare Advantage plans charge a daily copay starting on Day 1.Representing organizations that have contracts with Medicare; enrollment in any plan depends on renewal.

Elise Woehl
Elise Woehl

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