- In 2019, there were 10 Medicare Advantage Plans available in Delaware.
- 13% of the total Medicare population in Delaware is enrolled in Medicare Advantage Plans as of 2018.
- In 2018, Original Medicare spent an average of $9,823 per beneficiary in Delaware, which is 3% lower than the national average.
- Available Medicare Advantage Plans range from 17 to 19 across Delaware’s three counties.
Medicare Advantage Plans are similar to the private health insurance offered by employers. You’ll have different plans to choose from, each with different deductibles, premiums, and copays. Medicare Advantage Plans have a fixed network of hospitals and doctors, and depending on your plan, you may need to choose a primary care physician or get referrals to see a specialist.
Medicare Advantage Plans in Delaware
Types of Medicare Advantage Plans
Delaware’s Medicare Advantage program includes several types of plans, including HMOs, PPOs, PFFSs, and SNPs. Each plan has varying rules for what’s covered, out-of-pocket costs, and which doctors you’re able to see. All Medicare Advantage Plans include as much coverage as Original Medicare Parts A and B, and these plans often include additional benefits.
Health Maintenance Organizations (HMOs)
With HMO plans, you’re usually required to get care from providers in the plan’s network, except in cases of emergency care, out-of-area urgent care, or out-of-area dialysis. You usually need to choose a primary care provider, and you’ll need a referral to see a specialist in most cases (except yearly screening services, such as mammograms). Prescription drugs are typically covered under HMO plans.
Preferred Provider Organizations (PPOs)
PPO plans allow you to use any doctor, health care provider, or hospital in the plan’s network. You can also go outside of the network for care, but this tends to cost more. You don’t need to choose a primary care provider or get referrals to see specialists, so PPO plans are more flexible than HMOs. Like HMOs, PPO plans usually cover prescription drugs.
Private Fee-For-Service Plans (PFFS)
A PFFS plan allows you to use any doctor, health care provider, or hospital that accepts the plan’s terms of payment and agrees to treat you. PFFS plans determine how much you’ll pay for care and how much it will pay providers for the services you get. Referrals aren’t required to see a specialist, and you don’t need to pick a primary care doctor. Prescription drugs may be covered by PFFS plans.
Special Needs Plans (SNPs)
SNP plans are limited to people who have certain chronic conditions, have both Medicare and Medicaid, live in a nursing home, or require nursing care in their home. Plans tailor benefits, providers, and prescription drug formularies to best meet the needs of the groups served. You’re generally required to get care from in-network providers. You may be required to have a primary care doctor, and a referral is usually needed to see a specialist.
Enrollment and eligibility for Medicare Advantage Plans in Delaware
In Delaware, you can sign up for a Medicare Advantage Plan if you’re at least 65 years old or disabled, enrolled in Original Medicare Parts A and B, and not enrolled in Medigap insurance. You also need to live in the coverage area that the plan services.
There are certain enrollment periods when you can sign up for a Medicare Advantage Plan or switch to a different one. These include:
- Initial enrollment period. You can first sign up for a Medicare Advantage Plan during a seven-month period in the year you turn 65. This period starts three months before your 65th birthday includes the month you turn 65, and ends three months after your birth month. If you’re eligible for Medicare due to disability and turn 65, you can sign up for a plan or switch to a different one.
- Open enrollment period. The open enrollment period runs from October 15th to December 7th each year. During this time, you can switch, join, or drop a plan. Starting in 2021, people with end-stage renal disease (ESRD) can choose an Original Medicare plan or Medicare Advantage Plan during open enrollment.
- Medicare Advantage enrollment period. From January 1st to March 31st, you can switch to another Medicare Advantage Plan or switch to an Original Medicare Plan.
In certain circumstances, you can also make changes to a Medicare Advantage Plan outside of these regular enrollment periods. Events that qualify you for a Special Enrollment Period (SEP) include changing where you live, becoming eligible for an SNP, and losing your current coverage, among others.
Prescription drug coverage
Most Medicare Advantage Plans include drug coverage, although some, such as PFFS Plans, may not. If your plan doesn’t include prescription drugs, you can get coverage by enrolling in Medicare Part D. Medicare Part D adds drug coverage to Original Medicare plans, Medical Savings Account plans, and certain PFFS plans. If you apply for prescription drug coverage after your initial enrollment period is over, you’ll pay a late enrollment penalty, which is permanently added to your Medicare Part D premium.
Medicare Advantage Resources in Delaware
Before selecting a Medicare Advantage Plan, it’s a good idea to know all your options, so you can pick the one that’s the right match for you. In Delaware, you’ll find several organizations and agencies aimed at helping you choose the best Medicare Advantage Plan for your needs. All of the following services are provided free of charge.
Delaware Medicare Assistance Bureau
Formerly known as ELDERInfo, DMAB is Delaware’s State Health Insurance Assistance Program (SHIP). It provides one-on-one counseling and assistance with issues related to Medicare, Medicaid, Medigap, and Part D coverage. Volunteers are available in-person and over the phone to answer your questions about Medicare Advantage Plans and other types of health insurance. DMAB also offers Medicare Advantage community presentations online and at various locations throughout the state.
Contact Information: Website | (302) 674-7364
Delaware Aging and Disability Resource Center
The Delaware ADRC serves as a one-stop source of information about health insurance options, including Medicare plans, Medicaid, long-term care insurance, and more. ADRC can answer your questions about services for the elderly and disabled, and its staff can help you compare available plans and enroll in a Medicare Advantage Plan. It has a directory of resources on its website, where Delaware residents can search for Medicare counselors, educational programs, and a wide range of social services available near them.
Contact Information: Website | (800) 223-9074
Community Legal Aid Society
Community Legal Aid Society provides assistance and representation for individuals with legal concerns related to public benefits. Its attorneys help people who were denied benefits, including Medicare, Medicaid, SSI, and TANF, and work alongside them throughout the appeals process. Community Legal Aid Society also operates the Elder Law Program, which educates seniors about Medicaid plans and helps them understand their medical and insurance bills. The organization prioritizes low-income people and those aged 60 and older.
Contact Information: Website | (302) 575-0660
Learn More From Our Sources
- Medicare | Medicare Advantage Plans | Last accessed June 2021
- Medicare | Health Maintenance Organization (HMO) Plans | Last accessed June 2021
- Medicare | Preferred Provider Organization (PPO) Plans | Last accessed June 2021
- Medicare | Private Fee-for-Service (PFFS) Plans | Last accessed June 2021
- Medicare | Special Needs Plans | Last accessed June 2021
- Medicare | How Do Medicare Advantage Plans Work? | Last accessed June 2021
- Medicare | Joining a Health or Drug Plan | Last accessed June 2021
- Medicare | Drug Coverage (Part D) | Last accessed June 2021
- Medicare | Special Circumstances (Special Enrollment Periods) | Last accessed June 2021