MEDICARE ADVANTAGE
Medicare Advantage Plans include doctors, hospitals, and prescriptions in one plan.
Most at a zero to low monthly premium.
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A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
Health Maintenance Organization (HMO) Plan:
In HMO Plans, you can’t get your health care from any doctor, other health care provider, or hospital. You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services, usually for a higher cost. This is called an HMO with a point-of-service (POS) option. In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want Medicare prescription drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage. You will also need to choose your primary care doctor upfront before starting the HMO. Also in most cases, you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don’t require a referral.
What else do I need to know about an HMO?
If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.
It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.
Preferred Provider Organization (PPO) Plans:
How PPO Plans Work
A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C)offered by a private insurance company. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You pay more if you use doctors, hospitals, and providers outside of the network.
Can you get your health care from any doctor, other health care provider, or hospital?
In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. PPO Plans have network doctors, other health care providers, and hospitals. Each plan gives you the flexibility to go to doctors, specialists, or hospitals that aren’t on the plan’s list, but it will usually cost more.
Are prescription drugs covered?
In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn’t offer prescription drug coverage, you can’t join a Medicare Prescription Drug Plan (Part D).
Do you need to choose a primary care doctor?ggle Title
You don’t need to choose a primary care doctor in PPO Plans.
Do you have to get a referral to see a specialist?
In most cases, you don’t have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.
What else do you need to know about this type of plan?
A PPO Plan isn’t the same as Original Medicare or a Medicare Supplement Insurance (Medigap) policy.
PPO Plans usually offer extra benefits than Original Medicare, but you may have to pay extra for these benefits.
Private Fee-For-Service (PFFS) Plans:
How PFFS Plans Work
A Medicare PFFS Plan is a type of Medicare Advantage Plan (Part C)offered by a private insurance company. PFFS plans aren’t the same as Original Medicare or Medigap. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.
Can I get my health care from any doctor, other health care provider, or hospital?
In some cases, you can get your health care from any doctor, other health care provider, or hospital in PFFS Plans.
You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan’s payment terms and agrees to treat you. Not all providers will. If you join a PFFS Plan that has a network, you can also see any of the network providers who have agreed to always treat plan members. You can also choose an out-of-network doctor, hospital, or other provider, who accepts the plan’s terms, but you may pay more.
Are prescription drugs covered?
Prescription drugs may be covered in PFFS Plans. If your PFFS Plan doesn’t offer drug coverage, you can join a Medicare Prescription Drug Plan to get coverage.
Do I need to choose a primary care doctor?
You don’t need to choose a primary care doctor in PFFS Plans.
Do I have to get a referral to see a specialist?
You don’t have to get a referral to see a specialist in PFFS Plans.
What else do I need to know about this type of plan?
- Some PFFS Plans contract with a network of providers who agree to always treat you even if you’ve never seen them before.
- Out-of-network doctors, hospitals, and other providers may decide not to treat you even if you’ve seen them before.
- For each service you get, make sure your doctors, hospitals, and other providers agree to treat you under the plan and accept the plan’s payment terms.
- In an emergency, doctors, hospitals, and other providers must treat you.
- Show your plan membership ID card each time you visit a health care provider. Your provider can choose at every visit whether to accept your plan’s terms and conditions of payment. You can’t use your red, white, and blue Medicare card to get health care because Original Medicare won’t pay for your health care while you’re in the Medicare PFFS Plan. Keep your Medicare card in a safe place in case you return to Original Medicare in the future.
- You only need to pay the copayment or coinsurance amount allowed by the plan for the type(s) of service you get at the time of the service.
Medicare Special Needs Plans (SNP):
How Medicare SNPs work
Medicare SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics and tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.Find out who can join a Medicare SNP.
Can I get my health care from any doctor, other health care provider, or hospital?
Generally, you must get your care and services from doctors or hospitals in the Medicare SNP network (except emergency or urgent care, such as care you get for a sudden illness or injury that needs medical care right away, or if you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis). Medicare SNPs typically have specialists in the diseases or conditions that affect their members.
Are prescription drugs covered?
All SNPs must provide Medicare prescription drug coverage.
Do I need to choose a primary care doctor?
In most cases, SNPs may require you to have a primary care doctor, or the plan may require you to have a care coordinator to help with your health care.
Do I have to get a referral to see a specialist?
In most cases, you have to get a referral to see a specialist in SNPs. Certain services, like yearly screening mammograms or an in-network pap test and pelvic exam (covered at least every other year), don’t require a referral.
What else do I need to know about this type of plan?
- A plan must limit membership to these groups: 1) people who live in certain institutions (like a nursing home) or who require nursing care at home, or 2) people ho are eligible for both Medicare and Medicaid, or 3) people who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia). Plans may further limit membership. You can join a SNP at any time.
- Plans should coordinate the services and providers you need to help you stay healthy and follow doctor’s or other health care provider’s orders.
- If you have Medicare and Medicaid, your plan should make sure that all of the plan doctors or other health care providers you use accept Medicaid.
- If you live in an institution, make sure that plan providers serve people where you live. Find out more about where SNPs are offered.
There are other less common types of Medicare Advantage plans that may be available:
HMO Point of Service (HMOPOS) Plans: An HMO Plan that may allow you to get some services out-of-network for a higher cost.
Medical Savings Account (MSA) Plans: A plan that combines a high deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year.
