Medicare Advantage Plans

Medicare Advantage Plans are another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-approved private companies that must follow rules set by Medicare. Most Medicare Advantage Plans include drug coverage (Part D). In many cases, you’ll need to use health care providers who participate in the plan’s network and service area for the lowest costs. These plans set a limit on what you’ll have to pay out-of-pocket each year for covered services, to help protect you from unexpected costs. Some plans offer out-of-network coverage, but sometimes at a higher cost. Remember, you must use the card from your Medicare Advantage Plan to get your Medicare-covered services. Keep your red, white, and blue Medicare card in a safe place because you’ll need it if you ever switch back to Original Medicare. Below are the most common types of Medicare Advantage Plans.

Health Maintenance Organization (HMO)

In HMO Plans, you generally must get your care and services from providers in the plan’s network, except:

• Emergency care
• Out-of-area urgent care
• Out-of-area dialysis

In some plans, you may be able to go out-of-network for certain services. But, it usually costs less if you get your care from a network provider. This is called an HMO with a point-of-service (POS) option.

Are prescription drugs covered in Health Maintenance Organization (HMO) Plans?

In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want Medicare drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage.

Do I need to choose a primary care doctor in Health Maintenance Organization (HMO) Plans?

In most cases, yes, you need to choose a primary care doctor in HMO Plans.

Do I have to get a referral to see a specialist in Health Maintenance Organization (HMO) Plans?

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 this type of plan?

• If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.
• If you get health care outside the plan’s network , you may have to pay the full cost.
• It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.

Preferred Provider Organization (PPO)

How PPO Plans Work

A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PPO Plans have network doctors, other health care providers, and hospitals. 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. Each plan gives you 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 drug plan (Part D).

Do you need to choose a primary care doctor?

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, no. But if you use plan specialists (in-network), your costs for covered services will usually be lower than if you use non-plan specialists (out-of-network).

What else do you need to know about this type of plan?

• Because certain providers are “preferred,” you can save money by using them.
• A PPO Plan isn’t the same as Original Medicare or a Medicare Supplement Insurance (Medigap) policy.
• It usually offers extra benefits than Original Medicare, but you may have to pay extra for these benefits.
• Check with the plan for more information.

Private Fee-for-Service (PFFS) Plans

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 get your health care from any doctor, other health care provider, or hospital in PFFS Plans.

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 your costs will usually be lower if you stay in the network.

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 drug plan (Part D) 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 heath 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.

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. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.

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, like care you get for a sudden illness or injury that needs medical care right away
• 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 don’t require a referral, like these:

• Yearly screening mammograms
• An in-network pap test and pelvic exam (covered at least every other year)

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 who 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.

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