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 most cases, you’ll need to use health care providers who participate in the plan’s network. These plans set a limit on what you’ll have to pay out-of-pocket each year for covered services. Some plans offer non-emergency coverage out of network, but typically 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 may need to use your Medicare card for some services. Also, 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

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

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

HMO Point-of-Service (HMOPOS) plans are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance. It’s important that you follow the plan’s rules, like getting prior approval for a certain service when the plan requires it. Find and compare HMO Plans in your area.

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. If you join an HMO plan without drug coverage, you can’t join a separate Medicare drug plan.

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.

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.

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 can also use out‑of‑network providers for covered services, usually for a higher cost, if the provider agrees to treat you and hasn’t opted out of Medicare (for Medicare Part A and Part B items and services). You’re always covered for emergency and urgent care.

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.

Check with the plan for more information.

Private Fee-for-Service (PFFS) Plans

How PFFS Plans Work

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 contracted network of providers, you can also see any of the network providers who have agreed to always treat plan members. If you go to a doctor, other health care provider, facility, or supplier that doesn’t belong to the plan’s network for non-emergency or non-urgent care services, your plan may not cover your services, or your costs could be higher.

Note
You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan’s payment terms, agrees to treat you, and hasn’t opted out of Medicare (for Medicare Part A and Part B items and services). Not all providers will.

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 separate 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?

The plan decides how much you pay for services. The plan will tell you about your cost sharing in the “Annual Notice of Change” and “Evidence of Coverage” documents that it sends each year.

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.

Check with the plan for more information.

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. Find out who can join a Medicare SNP.

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

Some SNPs cover services out of network and some don’t. Check with the plan to see if they cover services out of network, and if so, how it affects your costs.

Medicare SNPs typically have specialists in the diseases or conditions that affect their members.

Are prescription drugs covered?

All SNPs must provide Medicare drug coverage (Part D).

Do I need to choose a primary care doctor?

Some SNPs require primary care doctors and some don’t. Check with the plan to see if you need to choose a primary care doctor.

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

Some SNPs require referrals and some don’t. Certain services, like yearly screening mammograms, don’t require a referral. Check with the plan to see if you need a referral.

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

These groups are eligible to enroll in an SNP: 1) people who live in certain institutions (like nursing homes) or who live in the community but 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 to a single chronic condition or a group of related chronic conditions. You can join a SNP at any time.

  • An SNP provides benefits targeted to its members’ special needs, including care coordination services.
  • 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. Find out more about where SNPs are offered.
  • Check with your plan for more information.