Types of Medicare Advantage Plans

Types of Medicare Advantage Plans

There are several different types of Medicare Advantage plans.

 

HMO (Health Maintenance Organizations)

HMOs account for the largest share (64%) of Medicare Advantage enrollment and have been available under Medicare for several years. HMOs are the most tightly managed plans and utilize a defined network of providers that beneficiaries generally must use to receive care (with some exceptions, such as emergency care).  If you get health care outside the plan’s network, you may have to pay the full cost.

  • Do I need to choose a primary care doctor?  In most cases, yes.
  • Do I have to get a referral to see a specialist?  In most cases, you need a referral.  Certain services, like yearly screening mammograms, don’t require a referral.

 

PPO (Preferred Provider Organizations)

PPOs also utilize provider networks. However, with PPOs, patients can choose to obtain care outside the network for a higher cost-share amount.

  • Do you need to choose a primary care doctor?  No.
  • Do you have to get a referral to see a specialist? No.  If you see a Plan specialists cost will usually be lower.

 

PFFS (Private Fee-for-Service Plans)

PFFS plans are more flexible than HMOs and PPOs because they are not required to establish provider networks. Patients can see “any willing Medicare-approved provider” if the provider accepts the plan’s terms and conditions.  However, some PFFS Plans now have a network. You can also choose an out-of-network doctor, hospital, or other provider, who accepts the plan’s terms, but you may pay more.

  • Do I need to choose a primary care doctor?  No.
  • Do I have to get a referral to see a specialist? No.

 

MSA (Medical Savings Accounts)

MSAs combine a high-deductible health plan with an MSA into which Medicare makes annual deposits on behalf of enrollees. Beneficiaries draw from these funds to pay for qualified health care expenses until they meet a deductible at which point the plan pays for all Medicare-covered services. MSA plans do not offer Medicare Part D prescription drug coverage.

 

SNP (Special Needs Plans)

SNPs were created specifically to serve individuals with special needs, including institutionalized individuals (individuals residing or expecting to reside for 90 days or longer in a long-term care facility), dual eligible (those individuals receiving both Medicare and Medicaid benefits), and other individuals with severe or disabling chronic conditions.

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