Medicare Advantage Part C Plans

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Click on the below type of Medicare Advantage Part C plan you would like to learn about:

Health Maintenance Organization (HMO)

Preferred Provider Organization (PPO)

Private-Fee-for-Service (PFFS)

Special-Needs-Plan (SNP)

Medicare Advantage Part C

What is Medicare Part C? MedicareFAQ is here to help you better understand Medicare and all the Supplemental plans that go along with it. By speaking with one of our licensed Medicare agents today we will be able to answer your questions quickly and easily.

We can help you better understand the plan or plans your researching and find the best plan at the best price for your exact needs. Give us a call today so we can help you choose the right plan for your needs and budget.

Medicare Advantage HMO (Health Maintenance Organization)

You just can’t get your health care from any hospital, other health care provider, or doctor. You generally must get your care and services from hospitals, other health care providers, or doctors in the plan’s network.

If you get health care outside the plan’s network, you may have to pay the entire cost. In some plans, you may be able to go out-of-network for certain services, usually for a higher cost. This is referred to as a Medicare Advantage HMO with a point-of-service (POS) option.

In most cases you have to get a referral to see a specialist in HMO Plans. In most cases you need to choose a primary care doctor in Medicare Advantage HMO Plans. Certain services, such as yearly screening mammograms, don’t require a referral.

If your doctor or other health care provider leaves the plan, your plan is required to notify you. You can choose another doctor in the plan. It is important that you stick to the plan’s rules, like getting advanced approval for certain services when needed.

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Medicare Advantage PPO

In a Medicare Advantage PPO Plan, you pay less if you use hospitals, doctors, and any other health care providers that belong to the plan’s network. You pay more if you use hospitals, doctors, and providers outside of the network.

Each plan gives you flexibility to go to hospitals, specialists, or doctors that aren’t on the plan’s list, but it will usually come with additional cost. You don’t have to choose a primary care doctor in Medicare Advantage PPO Plans.

You don’t have to get a referral to see a specialist in Medicare Advantage PPO Plans, in most cases. If you use plan specialists, your costs for any covered services will usually be negotiated lower than if you use non-plan specialists. Medicare Advanatage PPO Plans can offer extra benefits than Original Medicare, but you may have to pay extra for these benefits.

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Medicare PFFS (Private-Fee-for-Service)

Medicare PFFS plans aren’t the same as Medicare Advantage Part C or Medicare Supplement (Medigap). The plan predetermines how much it will pay any hospitals, other health care providers, and doctors, and how much you are required to pay when you get care.

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. If you join a Medicare PFFS Plan that has a network, you can also see any of the network providers who have agreed to always treat plan members.

You have choices for an out-of-network hospital, doctor, or other health care providers, who accepts the plan’s terms, but it’s possible you will pay more. Prescription drugs could be covered in PFFS Plans. If your Medicare PFFS Plan does not offer drug coverage, you can join a Part D plan to get coverage.

You are not required to choose a primary care doctor in PFFS Plans. Some Medicare PFFS Plans have agreements with a network of providers who agree to always provide care even if you’ve never seen them before.

Out-of-network hospitals, doctors, and other providers may decide not to treat you even if you’ve seen them previously. For each service you get, make sure your hospitals, doctors, and other health care providers agree to provide treatment for you under the plan, and accept the plan’s cost terms.

In an emergency, doctors, hospitals, and other providers are required to treat you. Providers can choose at every visit whether to accept a plan’s terms and conditions of payment.

You are not able to use Original Medicare to get heath care because Original Medicare will not pay for your health care while covered by a Medicare PFFS Plan. You only need to pay the co-payment, or coinsurance, amount allowed by the plan for the types of service you get at the time of the treatment.

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Medicare Special Needs Plans (SNP)

SNP, or Medicare Special Needs Plans, is another type of Medicare Advantage Part C (like a HMO or PPO). Medicare Special Needs Plans limit enrollment to people with specific diseases or characteristics, and adjust their provider choices, benefits, and drug formulates to best meet the certain needs of the groups they serve.

Generally, you must get your care and services from hospitals or doctors in the Medicare SNP network (except for emergency care, like you would receive for a sudden illness or injury that requires medical care right away, or if you have ESRD (End-Stage Renal Disease) and require out-of-network dialysis). Medicare Special Needs Plans typically have specialists in the diseases or conditions that affect their members.

All Medicare Special Needs Plans must provide Medicare prescription drug coverage. In most cases, 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.

In most cases, you have to get a referral to see a specialist in SNPs. Certain services, like yearly screening mammograms or an in-network Pap test and pelvic exam covered at least every other year, don’t require a referral.

A plan must limit enrollment to these grouped areas: 1-those who reside in certain institutions, like a nursing home, or who require at home nursing care. 2-those who are eligible for Medicare and Medicaid, together.

People who have specific disabling or chronic conditions (such as diabetes, End-Stage Renal Disease (ESRD), HIV, AIDS, dementia, or chronic heart failure). You can join a Medicare Special Needs Plans at any time when qualifying. 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.

When 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 treat people where you reside. If you’re still asking “What is Medicare Part C” don’t hesitate to call of our licensed agents now!

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