Medicare Advantage plans vary by the type of plan coverage you need. It is important to understand the different types of plans offered and the different type of coverage of each. These are the most common types of Medicare Advantage plans:
Health Maintenance Organization (HMO)
A contracted Medicare Health Maintenance Organization gives you access to a network of doctors and hospitals that coordinate your care, with an emphasis on prevention. Having this network of medical professionals allows you to receive more benefits than Original Medicare and various Medicare Supplement plans. However, an HMO plan may not cover medical treatments or care outside of the approved network without prior approval. Except in an emergency. Most generally, to see a specialist, you must get a referral from your primary care physician (PCP).
Typically, an HMO network provides medical services at a discounted rate and tend to be more cost-effective than other forms of health insurance.
There may be special circumstances that allow you to seek care outside of the network at a higher cost as an HMO point of service option (HMO POS).
Health Maintenance Organization with a Point of Service Option (HMO POS) –
This HMO plan is flexible by allowing you to seek treatment outside of the HMO network. Special situations and circumstances may apply with additional fees
Preferred Provider Organization (PPO)
With a Preferred Provider Organization, you have a network of providers like HMOs. However, you’re not required to stay within the network. Typically, because you are free to use whatever medical provider you choose, the cost of the premium is generally more expensive with the same benefits than the HMO. Using a provider in the network is generally cheaper with overall costs.
With a PPO, you’re do not have to choose a primary care physician, and you don’t need referrals to see a specialist. One advantage is that you are free to choose who you see for medical care and when you get treatment.
Most PPOs include prescription drug coverage; however, you will not be eligible for Part D through Medicare.
Private Fee-for-Service (PFFS)
Private Fee-for-Service plans are designed specifically for Medicare and allow you to see any doctor or health professional. You do not have to choose a PCP or get a referral for a specialist. However, the doctor or healthcare professional must be eligible to receive payments for Medicare and agrees to the plan’s rules and policies. While some PFFSs have networks, these networks agree to treat patients who are enrolled in the plan, regardless if they are a returning or new patient. You must confirm with the healthcare professional that they accept the PFF plan before treatment because they are free to choose on a patient-by-patient base and you will be responsible for the visit charges if seen and they do not accept the plan.
Medicare Special Needs Plans (SNPs)
A Special Needs plan is coverage designed especially for Medicare beneficiaries with certain chronic or specific health conditions or meets other qualifications. SNPs allow enrollment at first qualification without a specific enrollment period. Enrollment qualifications include you must be enrolled in both Medicare Part A and B and live in the country of the plans service area. If you live in a nursing home or other institution or you receive both Medicare and Medicaid, you may qualify for SNP.
SNP plans typically require you choose a PCP or care coordinator and to use providers in the network and requires a referral to a specialist. Emergencies being the exception or if you need kidney dialysis outside your plan’s service area.
SNPs typically provide prescription drug coverage.
Since this is not a complete list of qualifications for SNP, please contact the specific plan for more details.
Medical Savings Account (MSA)
A medical savings account is another version of a health savings account. They are less common, and may not be available in all areas, and may have higher deductibles. There are two parts to an MSA, a health insurance plan and a special savings account where the insurance company deposits money into the savings account for you to pay any healthcare-related expenses, regardless if Medicare covers them. This money is not taxed unless you spend it on non-healthcare expenses. Money spent on Medicare-covered healthcare count towards the plan’s yearly deductible. MSAs do not include prescription drug coverage.
This information is not a complete description of benefits. Contact the specific plan in question for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or copayments/co-insurance may change yearly.