What is Medicare Advantage?
Medicare Advantage (MA) Plans, or Part C are offered by Medicare-approved private companies who are required to offer coverage equal to or greater than coverage offered by Original Medicare. Most, but not all, Medicare Advantage Plans include drug coverage (Part D). Many MA plans have a network of providers. You will have the most cost savings by using health care providers who participate in the plan’s network and service area. 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.
Medicare Advantage (MA) Plans, or Part C are offered by Medicare-approved private companies who are required to offer coverage equal to or greater than coverage offered by Original Medicare. Most, but not all, Medicare Advantage Plans include drug coverage (Part D). Many MA plans have a network of providers. You will have the most cost savings by using health care providers who participate in the plan’s network and service area. 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) Plans
- Preferred Provider Organization (PPO) Plans
- Private Fee-for-Service (PFFS) Plans
- Special Needs Plans (SNPs)
Health Maintenance Organization (HMO) Plans
In HMO Plans, you generally must get your care and services from providers in the plan's network, except:
Are Prescription Drugs Offered in an HMO Plan?
Usually, yes. Most HMO plans cover prescriptions drugs (Part D). Discuss plan details with your agent to make sure you are getting the plan that is best for you. Remember, if you join an HMO Plan that doesn't offer prescription drug coverage, you can't join a Medicare drug plan (Part D).
Do I need to choose a primary care provider (PCP) in an HMO Plan?
Usually, yes. Most HMO Plans will require you to choose an in network PCP. Your agent can help you find an in network PCP.
Do I need to get a referral to see a specialist with an HMO Plan?
Usually, yes. 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?
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
Are Prescription Drugs Offered in an HMO Plan?
Usually, yes. Most HMO plans cover prescriptions drugs (Part D). Discuss plan details with your agent to make sure you are getting the plan that is best for you. Remember, if you join an HMO Plan that doesn't offer prescription drug coverage, you can't join a Medicare drug plan (Part D).
Do I need to choose a primary care provider (PCP) in an HMO Plan?
Usually, yes. Most HMO Plans will require you to choose an in network PCP. Your agent can help you find an in network PCP.
Do I need to get a referral to see a specialist with an HMO Plan?
Usually, yes. 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?
- 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 get prior approval for a certain service when needed.
Preferred Provider Organization (PPO) Plans
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.
How can I get service from a physician or facility?
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. Your plan or agent can help you find an in network provider.
Are prescription drugs covered?
Usually, yes. In most cases, prescription drugs are covered in PPO Plans. Discuss plan details with your agent to make sure you are getting the plan that is best for you. 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 I need to choose a primary care provider?
No. You don't need to choose a primary care doctor in PPO Plans.
Do I have to get a referral to see a specialist?
Usually no. If you use an in network specialists, your costs for covered services will usually be lower than if you use non-plan specialists (out-of-network).
What else do I need to know?
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.
How can I get service from a physician or facility?
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. Your plan or agent can help you find an in network provider.
Are prescription drugs covered?
Usually, yes. In most cases, prescription drugs are covered in PPO Plans. Discuss plan details with your agent to make sure you are getting the plan that is best for you. 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 I need to choose a primary care provider?
No. You don't need to choose a primary care doctor in PPO Plans.
Do I have to get a referral to see a specialist?
Usually no. If you use an in network specialists, your costs for covered services will usually be lower than if you use non-plan specialists (out-of-network).
What else do I need to know?
- Because certain providers are preferred, you can save money by using them.
- Check with the plan or speak with your agent for more information.
Private Fee-for-Service (PFFS) Plans
PFFS plans determine 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 service from any healthcare provider or facility?
Sometimes. Some PFFS Plans allow you get your health care from any doctor, other health care provider. 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 go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan's payment terms and agrees to treat you. Not all providers will.
Are prescription drugs covered?
Sometimes. If your PFFS Plan doesn't offer drug coverage, you can join a stand alone Part D drug plan to get coverage.
Do I have to get a referral to see a specialist?
No.
What else do I need to know?
PFFS plans determine 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 service from any healthcare provider or facility?
Sometimes. Some PFFS Plans allow you get your health care from any doctor, other health care provider. 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 go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan's payment terms and agrees to treat you. Not all providers will.
Are prescription drugs covered?
Sometimes. If your PFFS Plan doesn't offer drug coverage, you can join a stand alone Part D drug plan to get coverage.
Do I have to get a referral to see a specialist?
No.
What else do I need to know?
- 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 (SNP) Plans
SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics. SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.
Can I get service from any healthcare provider or facility?
Usually. You must get your care and services from doctors or hospitals in the SNP plan's 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
Are prescription drugs covered?
Yes.
Do I need to choose a primary care provider?
Usually. 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?
Usually. 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?
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
2) people who are eligible for both Medicare and Medicaid
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.