Medicare Advantage (MA) plans come in a wide variety of packages.  Additionally, MA options vary by service area.  An option available to a relative in a county near you may not be available in a different county.  Another challenge when selecting a Medicare Advantage plan is the quantity and types of plans insurance companies offer.

Without going into great detail about Medicare Advantage plans, there are a few big-picture things to consider.  MA plans are often referred to as Part C.  They do not work hand-in-hand with Original Medicare as supplements do.  Individuals with such coverage present the MA card to the provider.  In addition, many MA plans include prescription coverage.  Several MA plans include ancillary benefits that Original Medicare does not include such as basic dental, vision, hearing, and fitness programs.  A page with general MA plan information is available here.  Below is some basic information about the types of Medicare Advantage plans.

Preferred Provider Organization (PPO)

  • PPO Plans include network doctors, other health care providers, and hospitals. Individuals pay less when using doctors, hospitals, and other health care providers that belong to the plan’s network.  Individuals pay more when using doctors, hospitals, and providers outside the network.
  • In many cases, prescription drugs are covered in PPO plans. For Medicare drug coverage, individuals must join a PPO Plan that offers prescription drug coverage. Remember, if one joins a PPO Plan that doesn’t offer prescription drug coverage, one cannot join a Medicare drug plan (Part D).
  • Some employer group plans are PPOs.

Health Maintenance Organization (HMO)

  • HMO Plan enrollees generally must receive care and services from providers in the plan’s network, except when receiving emergency care, out-of-area urgent care, or out-of-area dialysis.
  • HMO Plans require the designation of a primary care physician (PCP).
  • Referrals are required to see an in-network specialist.
  • Prescription drugs are covered in most HMO plans. To have Medicare drug coverage (Part D), individuals must join an HMO Plan that offers prescription drug coverage.
  • HMO Plans often have lower premiums than other types of Medicare Advantage plans. Often times, zero-premium plans are available too.

Private Fee-for-Service (PFFS)

  • This type of plan determines how much it will pay doctors, other health care providers, and hospitals, and also the amount an individual must pay when receiving care.
  • In some cases, individuals receive health care from any doctor, other health care provider, or hospital in PFFS Plans. If a PFFS Plan has a network, individuals may also see any of the network providers who have agreed to always treat plan members.  Another option is to choose an out-of-network doctor, hospital, or other provider who accepts the plan’s terms, and the cost will usually be lower from doctors in the network.
  • PFFS Plans do not require individuals to choose a primary care physician nor do they require referrals to see specialists.
  • Prescription drugs may be covered in PFFS Plans. If a selected PFFS Plan doesn’t offer drug coverage, individuals may join a Medicare drug plan (Part D)to get coverage.

Health Maintenance Organization Point of Service (HMO-POS)

  • This Medicare Advantage plan is like an HMO, but it may allow individuals to receive care outside the plan network.
  • HMO-POS Plans allow individuals to go to providers outside the plan’s provider network but might charge a higher copay or coinsurance fee.

Special Needs Plans (SNP)

  • Medicare SNPs limit membership to individuals with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.
  • Generally, individuals must receive care and services from doctors or hospitals in the Medicare SNP network. Exceptions include emergency care (for a sudden illness or injury) or urgent care (such as End-Stage Renal Disease (ESRD) and/or out-of-area dialysis).
  • Medicare SNPs typically have specialists in the diseases or conditions that affect their members.
  • All SNPs must provide Medicare prescription drug coverage.
  • Most SNPs require a primary care physician or care coordinator. Referrals to see specialists are often required.
  • These plans allow enrollment anytime an individual qualifies, rather than during a specific enrollment period.
  • SNPs limit membership to these groups: 1) people who live in certain institutions (i.e. a nursing home) or who require nursing care at home; 2) people who are eligible for both Medicare and Medicaid; 3) people who have specific chronic or disabling conditions (i.e. diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia). Plans may further limit membership.

Medical Savings Account (MSA)

  • This Medicare Advantage plan has a high deductible but sets up a bank account to use for health-care costs before paying a deductible.
  • MSAs allow individuals to use any doctor who accepts Medicare assignment.
  • Some MSAs include additional coverage (possibly for higher premiums), such as routine dental or vision services.
  • MSAs do not cover prescription drugs (besides the limited coverage included in Medicare Part A and Part B).

As mentioned previously, insurance companies may offer all of these options, a selection of these options, or none in specific service areas.  Selecting a Medicare Advantage plan that meets an individual’s needs may take time.  We encourage you to work with a professional to make sure your needs and desires are met.  Please Click on the Blue Button below or click here for assistance in selecting your plan.

Justin Eggenberger

Medicare Advisor

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