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.

5 Comments

  1. Re: Diabetes
    What to do about what private insurance covers and medicare does not cover?

    Reply
  2. I have an Anthem MediBlue Dual Advantage Plan (HMO SNP) – can you tell me what home health care agencies are available and covered by this plan in the Waterbury, CT area?? Would really appreciate your letting me know ASAP……
    Thank you!

    Reply
  3. Quite misleading, as to PPOs. In Florida, yes, you may choose an out of network doctor. But if you ever have go to the hospital, out of network providers will be forced upon you without your knowing it until you get the bill. This is true even if you are an emergency patient.

    This is worse than bait and switch. If you know that your doctor is in network and your hospital is in network, it’s just plain price gouging to foist out of network providers on emergency patients!

    Reply
  4. Very difficult to determine in-network providers particularly concerning dental, vision, and wheelchair services. Online tools require zip codes and do not respond correctly when mileage is increased — i.e. giving a company in Iowa when inquiring about Maryland and Delaware. Also drug costs incredibly inconsistent before gap. Chiropractor network participants also hard to get. Lists need to be updated! And coverage should be extended at a more favorable rate to out of network providers. I contacted seven dentists on lists and phone reps kept referring me to the same ones, even though I had asked that they forward a note on the invalid ones. Appreciate the drug coverage, but feel like I’ve had to give up medical parts coverage because of lack of network providers.

    Reply
  5. Do I have dental care coverage through humana gold plus in Florida.

    Reply

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