Medicare Advantage Plans In New Jersey

Fact Checked
Published: 6/4/2021

Medicare Advantage Plans offer an alternate way to get your Original Medicare Parts A and B benefits. These plans, which are also referred to as Medicare Part C, are provided by private health insurance companies that must follow specific rules and regulations mandated by the federal government. Along with Parts A and B benefits, Medicare Advantage Plans often include perks such as prescription drug, vision, and dental coverage, and discounts for health and wellness programs. Out-of-pocket costs are generally limited, which may make Medicare Advantage a good option for those managing chronic conditions.





  • In 2019, there were 49 Medicare Advantage Plans available in New Jersey.
  • 22% of the total Medicare population in New Jersey was enrolled in Medicare Advantage Plans as of 2018.
  • In 2018, Original Medicare spent an average of $10,793 per beneficiary in New Jersey, which is 7% higher than the national average.
  • Available Medicare Advantage Plans range from 11 to 43 across New Jersey’s 21 counties.

If you qualify for both parts of Original Medicare, then you’re eligible for Medicare Advantage. While Original Medicare can be used at any health care provider that accepts Medicare, Medicare Advantage Plans often have provider networks and rules about choosing a primary care doctor and getting referrals to see specialists. While there are over four dozen Medicare Advantage Plans available in New Jersey, your options depend on where you live and which health insurance company you choose.

Medicare Advantage Plans in New Jersey

Types of Medicare Advantage Plans

If you’re accustomed to private health insurance through an employer or the federal Marketplace, then New Jersey’s Medicare Advantage program may seem familiar. Depending on where you live, available options include HMOs, PPOs, PFFS plans, and SNPs. Each plan type has its own rules about prescription drug coverage, where you can use your health insurance, and get prior approval for certain services. Regardless of the plan you chose, you pay the monthly premium for Part B coverage. Some plans also have monthly premiums to cover the additional coverage.

Health Maintenance Organizations (HMO)

HMOs are among the most popular Medicare Advantage Plan types, mainly due to affordability. With this type of plan, you get Medicare services through a specific network of doctors, specialists, and hospitals. You’re generally required to choose a primary care physician who’s responsible for providing most of your care, and you may have to get a referral to see a specialist. Every plan is different, but common costs associated with HMOs include monthly premiums, medical or prescription drug deductibles, and copays for services and medications.

Preferred Provider Organizations (PPO)

PPO plans offer a greater degree of flexibility than HMOs. The plans have in-network providers that you can visit for the most affordable care. However, you also have the option of going to out-of-network providers and still having a portion of your medical expenses covered, although you may pay 40-50% more for out-of-network care. You usually aren’t required to choose a primary care doctor or get a referral to see a specialist.

Private Fee-For-Service Plans (PFFS)

PFFS plans work similarly to Original Medicare with schedules of what is covered and what you must pay for medical services. Most plans have established networks of health care providers that have contracted to always accept the plan’s payment terms. You can get care from an out-of-network provider that agrees to the plan’s terms, but your costs will probably be higher than if you’d stayed in-network. You usually don’t have to get a referral to see a specialist or choose a primary care physician.

Special Needs Plans (SNP)

SNPs are special Medicare Advantage Plans tailored to meet the needs of those who fulfill certain qualifications. You may qualify for an SNP if you’re dually eligible for Medicare and Medicaid, have a chronic condition such as diabetes, or live in a nursing home. These plans have benefits and networks that are oriented around your needs. For example, if you live in an institution, you may qualify for a plan that covers more skilled nursing services, or if you have an autoimmune disorder, your provider network may be comprised of doctors who specialize in treating that condition.

Enrollment and eligibility for Medicare Advantage Plans in New Jersey

Eligibility  

If you’re eligible for both parts of Original Medicare, then you’re eligible for Medicare Advantage. This typically occurs if you’re over 65 or are permanently disabled. To enroll in a plan, you have to live in your plan’s service area. Since plans typically have networks, you may want to ensure that your plan covers out-of-network care if you often travel or live in another state for part of the year. SNPs have additional eligibility requirements.

Enrollment Periods 

There are designated enrollment periods during which you can sign up for Medicare Advantage or switch health care plans.

  • Initial Enrollment Period.This period opens up three months prior to your birth month, includes your birth month, and extends three months after.
  • Open Enrollment Period. This annual enrollment period runs from October 15 to December 7. Any changes you make to your coverage take effect on January 1 of the following year.
  • Medicare Advantage Open Enrollment Period. This period goes from January 1 through March 31. If you’re enrolled in Medicare Advantage, you can switch to a different MA plan or to Original Medicare during this period.

Unlike other Medicare Advantage Plans, SNPs don’t have designated enrollment periods. If you become eligible for an SNP and there’s one available to you, you can enroll at any time.  Additional enrollment opportunities may occur if you move out of or into a coverage area or lose your employer benefits.

Prescription drug coverage

Prescription drug coverage, also called Medicare Part D, helps you cover the cost of prescribed medication. There are two ways to get this coverage, including selecting a Medicare Advantage Plan that includes this coverage or adding a Part D plan to your policy. If you are signing up for an HMO or PPO plan and you want prescription drug coverage, you must choose a plan that includes this coverage because you can’t add Part D to your policy. All SNPs are required to include prescription drug coverage. PFFS plans usually include this coverage, but if yours doesn’t, you can add a Part D plan for an additional monthly premium.

Medicare Advantage Resources in New Jersey

With so many Medicare Advantage options to consider, it’s helpful to get guidance from industry experts to assist you in making informed decisions. New Jersey is home to several organizations and departments that provide comprehensive information about available policies, enrollment deadlines, and things to consider before signing up for a plan.

Department of Banking & Insurance | Division of Insurance

The insurance industry in New Jersey is regulated by the state’s Department of Banking & Insurance. Through the Division of Insurance, you can get information on how health insurance claims are handled and what to do if a claim is denied.

Contact Information: Website | 800-446-7467

State Health Insurance Assistance Program

You can get free, unbiased assistance with Medicare-related issues through SHIP. The program’s trained volunteers can help you understand your benefits, compare Medicare Advantage Plans, find the best prescription drug coverage for your needs, and appeal denied coverage. Volunteers can also advise you about income-based programs that can help cover your Medicare expenses, including NJ Save.

Contact Information: Website | 800-792-8820

New Jersey Area Agencies on Aging

Each county in New Jersey is home to an Area Agency on Aging that provides a broad array of federally funded services and supports for seniors. At the AAA serving your area, you can access free Medicare options counseling and civil legal services to help you obtain coverage and resolve issues with your policy.

Contact Information: Website | 877-222-3737

Senior Medicare Patrol NJ

Medicare fraud and abuse are prevalent in New Jersey. To help you protect yourself from scams, the state’s Senior Medicare Patrol provides information and advocacy. Its volunteers can help you identify and resolve billing discrepancies and errors. They can also make referrals to law enforcement and health care agencies for incidents of suspected fraud, abuse, or waste.

Contact Information: Website | 877-767-4359

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