Medicare Advantage Plans

What are Medicare Advantage Plans?

A Medicare Advantage Plan (like an HMO or PPO) is another way to get your Medicare 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. If you join a Medicare Advantage Plan, you’ll still have Medicare but you’ll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage Plan, not Original Medicare. In most cases, you’ll need to use health care providers who participate in the plan’s network. Some plans offer out-of-network coverage. Remember, in most cases, you must use the card from your Medicare Advantage Plan to get your Medicare-covered services. Keep your Medicare card in a safe place because you’ll need it if you ever switch back to Original Medicare.

What are the different types of Medicare Advantage Plans?

• Health Maintenance Organization (HMO) plans
• Preferred Provider Organization (PPO) plans
• Private Fee-for-Service (PFFS) plans
• Special Needs Plans (SNPs)
• HMO Point-of-Service (HMOPOS) plans: These are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance.
• Medical Savings Account (MSA) plans: These plans combine a high-deductible health plan with a bank account that the plan selects. The plan deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year. MSA Plans don’t offer Medicare drug coverage. If you want drug coverage, you have to join a Medicare Prescription Drug Plan. For more information on MSA Plans, visit Medicare.gov. To find out if an MSA Plan is available in your area, visit Medicare.gov/find-a-plan.

Medicare Advantage Plans cover all Medicare Part A and Part B services

In all types of Medicare Advantage Plans, you’re always covered for emergency and urgent care. Medicare Advantage Plans must cover all of the services that Original Medicare covers. However, if you’re in a Medicare Advantage Plan, Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies.

Some Medicare Advantage Plans offer coverage for things that aren’t covered by Original Medicare, like vision, hearing, dental, and other health and wellness programs. Most include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you might have to pay a monthly premium for the Medicare Advantage Plan.

What do I pay?

• Your out-of-pocket costs in a Medicare Advantage Plan depend on:
• Whether the plan charges a monthly premium. You pay this in addition to the Part B premium.
• Whether the plan pays any of your monthly Medicare premiums. Some Medicare Advantage Plans will help pay all or part of your Part B premium. This benefit is sometimes called a “Medicare Part B premium reduction.”
• Whether the plan has a yearly deductible or any additional deductibles for certain services.
• How much you pay for each visit or service (copayments or coinsurance).
• The type of health care services you need and how often you get them.
• Whether you get services from a network provider or a provider that doesn’t contract with the plan.
• Whether you go to a doctor or supplier who accepts assignment (if you’re in a Preferred Provider Organization, Private Fee-for-Service Plan, or Medical Savings Account Plan and you go out-of-network).
• Whether the plan offers extra benefits (in addition to Original Medicare benefits) and if you need to pay an extra premium for them.
• The plan’s yearly limit on your out-of-pocket costs for all medical services. Once you reach this limit, you’ll pay nothing for covered services.
• Whether you have Medicaid or get help from your state.

Types of Medicare Advantage Plans

Health Maintenance Organization (HMO) plan

Can I get my health care from any doctor, other health care provider, or hospital?

No. You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services, usually for a higher cost. This is called an HMO with a point-of-service (POS) option.

Are prescription drugs covered?

In most cases, yes. If you want Medicare drug coverage, you must join an HMO plan that offers prescription drug coverage.

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, yes. 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’s network, your plan will notify you. You may choose another doctor in the plan’s network.
• 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.
• If you need more information than what’s listed on this page, check with the plan.

Preferred Provider Organization (PPO) plan

Can I get my health care from any doctor, other health care provider, or hospital?

In most cases, yes. PPO plans have network doctors, other health care providers, and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost.

Are prescription drugs covered?

In most cases, yes. If you want Medicare drug coverage, you must join a PPO plan that offers prescription drug coverage.

Do I need to choose a primary care doctor?

No.

Do I have to get a referral to see a specialist?

In most cases, no.

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

• PPO plans aren’t the same as Original Medicare or Medigap.
• Medicare PPO plans usually offer more benefits than Original Medicare, but you may have to pay extra for these benefits.
• If you need more information than what’s listed on this page, check with the plan.

Private Fee-for-Service (PFFS) plan

Can I get my health care from any doctor, other health care provider, or hospital?

You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan’s payment terms and agrees to treat you. 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 you may pay more.

Are prescription drugs covered?

Sometimes. If your PFFS plan doesn’t offer drug coverage, you can join a Medicare Prescription Drug Plan to get coverage.

Do I need to choose a primary care doctor?

No.

Do I have to get a referral to see a specialist?

No.

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

• PFFS plans aren’t the same as Original Medicare or Medigap.
• The plan decides how much you pay for services.
• 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 to show your plan member card before you get treated.
• In a medical emergency, doctors, hospitals, and other providers must treat you.
• If you need more information than what’s listed on this page, check with the plan.

Special Needs Plan (SNP)

Can I get my health care from any doctor, other health care provider, or hospital?

You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis).

Are prescription drugs covered?

Yes. All SNP plans must provide Medicare prescription drug coverage.

Do I need to choose a primary care doctor?

Generally, yes.

Do I have to get a referral to see a specialist?

In most cases, yes. Certain services, like yearly screening mammograms, don’t require a referral.

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 nursing homes) 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, HIV/AIDS, chronic heart failure, or dementia). Plans may further limit membership.
• Your plan will coordinate the services and providers you need to help you stay healthy and follow doctors’ or other health care providers’ orders.
• Visit Medicare.gov/find-a-plan to see if there are SNPs available in your area.
• If you need more information than what’s listed on this page, check with the plan.

For more information, please refer to the Medicare and You Handbook or contact us!