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If you live in New Jersey and are looking up Medicare Advantage plan options, read our guide as we break down what you need to know before you enroll.

By Jackie Trovato
Updated June 29, 2020

Key Takeaways:

  • There are pros and cons to both HMOs and PPO Medicare Advantage plans in New Jersey.

  • Medicare Advantage HMOs require you to stay within their network for care, or you'll have to pay more.

  • Medicare Advantage HMO drug costs and monthly premiums are typically lower than with other plans.

  • Medicare Advantage PPOs in New Jersey provide you the flexibility to go to doctors, specialists, or hospitals that aren't in the plan's list.

  • If you join a Medicare Advantage PPO plan that doesn't offer prescription drug coverage, you won't be allowed to join a Medicare prescription drug plan (Part D).

Medicare Advantage plans in New Jersey cover everything included in both Medicare Part A and Part B, as well as other healthcare services like dental, vision, hearing, and prescription drug coverage.

As of May 2020, 1,193,195 New Jersey residents were enrolled in Medicare. If you are one of them, you can sign up for a Medicare Advantage plan in NJ. Take a look at all the Medicare Advantage plans for 2020 that are available in New Jersey.

How Do Costs for Medicare Advantage Plans In NJ Compare to Those In Other States?

If you're considering a Medicare Advantage plan in New Jersey, there are quite a few you can choose from depending upon the county where you live. Premiums range from $0 a month to $196.40. That's a vast gap in price. The reason for this is because the benefits vary among plans.

When ranking all the states (except Alaska which doesn't provide Medicare Advantage), New Jersey ranks 27th in cost, with one being the least expensive and 50 being the most costly.

The average monthly rated cost for a Medicare Advantage plan in New Jersey is $27. The highest monthly weighted cost is in Minnesota at $50, and the lowest are Florida, Louisiana, Nebraska, South Carolina, and Texas at an average monthly cost of $5.

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What are the Pros and Cons of Medicare Advantage Plans In NJ?

As you can see, depending upon where you live, plans run the gamut from basic Health Maintenance Organization (HMO) plans to those with drug plans. There is also a variety of Preferred Provider Organization (PPO) plans, and even some that combine HMOs with PPOs.

So, what type of Medicare Advantage plan in New Jersey should you choose?

There are pros and cons with each of the available Medicare Advantage plans in New Jersey. We'll explain some of them here.

The Advantages of Using an HMO Medicare Advantage Plan In NJ

There are some real cost advantages to consider when using an HMO Medicare Advantage plan in New Jersey:

  • Your monthly premiums will be lower than when using another type of plan (like a PPO)

  • You won't have to file claims for reimbursements of medical costs

  • You will generally be offered a lower out-of-pocket cost for your prescription medications

In most cases, your prescription drugs will be covered in a Medicare Advantage HMO plan. Medicare Advantage HMOs keep your drug costs lower because they often prescribe only the generic form of a prescription medication. Just be sure that you are joining an HMO Medicare Advantage plan that includes Medicare Part D (prescription drug plans).

The Disadvantages of Using an HMO Medicare Advantage Plan In NJ

With an HMO plan, you are typically required to receive health care services from the specific providers in their network. If you don't, you will pay more for your services. There are three exceptions — these include healthcare for:

  • Medical emergencies

  • Urgent care when you're out of the area

  • Dialysis when you're out of the area

This can be a disadvantage for those who would rather see a healthcare provider who isn't in the HMO plan. With some HMO Medicare Advantage Plans in New Jersey, you might be allowed to go out-of-network for certain healthcare services. This is called an HMO with a point-of-service option.

Remember, Medicare coverage will always cost more if you use a provider or service outside the HMO Medicare plan in New Jersey. In some cases, if you get healthcare outside the plan's network, you may have to pay the full cost of the service.

HMOs keep drug costs down by usually prescribing only the generic form of medications. Because of this, if you prefer a particular brand-name medicine, it may not be covered and you will have to pay full price for it.

You will also need to get a referral to see a specialist with an HMO Medicare Advantage plan in New Jersey. This includes things like annual screening mammograms.

You will have one primary care provider in the HMO plan that you choose. This doctor coordinates all of your healthcare visits. To see a specialist, your primary care provider must authorize the appointment and provide a referral (unless it's for emergency care).

There may also be restrictions for the number of times you are allowed to receive services from a specialist without going back to your primary care doctor for a referral. For some, this can be a nuisance because it requires an extra step to receive specialty care.

Plus, in some cases, if the primary care physician believes that he or she can render this service just as well, a specialty visit can be denied.

The Benefits of Using a PPO Medicare Advantage Plan In NJ

Each Medicare Advantage PPO plan provides you the flexibility to go to doctors, specialists, or hospitals that aren't in the plan's list (however, it will usually cost more). You'll pay less when you see doctors, hospitals, and healthcare providers in the Advantage PPO plan's network.

With a Medicare Advantage PPO plan, you won't be tied to just one primary care doctor. You can visit any primary care doctor in the network without paying extra. You don't even need to choose a primary care doctor with a Medicare Advantage PPO plan. But, you will pay more if you go outside the plan.

In most cases, no referrals are required. Just like an HMO, a Medicare Advantage PPO plan has its own network of doctors and hospitals. If you use the PPO's specialists, your covered services will usually cost less than if you use non-plan specialists.

With most PPO Medicare Advantage plans in New Jersey, prescription drugs are covered. Just be sure that you join a PPO plan that offers prescription drug coverage.

Plus, Medicare Advantage PPO plans in New Jersey typically offer extra benefits than what Original Medicare provides, but you may be required to pay extra for these benefits.

The Disadvantages of Using a PPO Medicare Advantage Plan In NJ

Just like a Medicare Advantage HMO, you'll pay more if you use doctors, hospitals, and providers outside of the PPO network.

If you join a Medicare Advantage PPO plan in New Jersey that doesn't offer prescription drug coverage, you won't be allowed to join a Medicare prescription drug plan (Part D). So, if you want drug coverage, be sure that your Advantage PPO plan in NJ provides it.

Where Can You Go For More Information About Medicare Advantage Plans in NJ?

Medicare enrollees in New Jersey often have questions about benefits, claims, and Medicare Advantage plans. If you do, you can call New Jersey's State Health Insurance Assistance Program (SHIP). You can reach SHIP at 1-800-792-8820 or visit: https://www.state.nj.us/humanservices/doas/services/ship/.

SHIP is a statewide program administered by the New Jersey Department of Human Services. They provide help with questions and concerns about Medicare coverage. This service is free of charge to New Jersey Medicare beneficiaries who have problems with, or questions about, their health insurance.

Jackie Trovato is a healthcare and legal writer with nearly 40 years of experience.