There are different Medicare Advantage plan types that can be hard to understand since select plans are available in certain areas. Below, we’ll discuss the 4 types of Medicare Advantage plans.
The Different Types of Medicare Advantage Plans
Medicare Advantage plans include HMO, PPO, SNP, PFFS, and MSA. These plans and plan types come with a ton of information.
Medicare Advantage Plans are private insurance plans that help with gaps in Medicare coverage. Although they sound like Medigap plans, don’t confuse the two as they have some notable differences.
To be eligible for Advantage enrollment, you must enroll in Parts A and B and be current on Part B premium payments.
Beneficiaries with End-Stage Renal Disease (ESRD), won’t qualify for Advantage plans
About 30% of recipients choose Advantage plans over Medigap plans due to the cost of premiums being much lower. The only premium cost you must pay for MA is your monthly Part B premium.
Your Advantage plan will pay for the cost of healthcare bills, rather than Medicare. Beneficiaries pay expenses for services from providers in the plan’s network. Although the value of copayments is reasonable, you’ll want to still look over them before enrollment.
Many Advantage plans come with a Part D coverage plan, so enrolling in a separate drug plan isn’t necessary. For some, the convenience of this is great!
On the contrary, some beneficiaries have seen financial devastation. Check your Advantage plan’s drug formulary to ensure your prescriptions is enough. Otherwise, the cost of meds can be quite expensive.
When choosing a Part C plan, you’ll need to consider the different plan types to ensure proper coverage. We’ve broken down each plan type to help you better understand coverage options.
What are the Four Types of Medicare Advantage Plans?
With Medicare Advantage, the main options include Health Maintenance Organization, Preferred Provider Organization, Private Fee For Service, and Special Needs Plans.
Health Maintenance Organization (HMO)
For beneficiaries with HMO plans to receive coverage for care, you must receive services from doctors in your plan’s network.
Some plans allow you to get care from an out-of-network doctor; although, the cost will be higher. Being able to see out-of-network doctors on an HMO means there is a point-of-service (POS) option.
For most, a referral requirement for a specialist is in place.
Should your doctor or health care doctor leave, your plan notifies you. Following notification, you’ll be able to choose another doctor within the program.
Preferred Provider Organization (PPO)
With a Medicare Advantage PPO plan, you’ll pay less when visiting doctors, hospitals, or any health care provider when they belong to the plan’s network.
Each PPO gives freedom to go to hospitals and see specialists/doctors that aren’t on your plan’s list. Be mindful, though, as these services come with additional costs.
PPO plans give you the freedom to see any doctor. Opposite of HMO, it’s not necessary to choose a primary care doctor with PPO, and referrals aren’t a must.
Medicare Advantage PFFS plans are different from other types of Advantage plans. Beneficiaries can seek health care from any Medicare doctor, or hospital that agrees to the plan’s payment terms and grants treatment of services.
Nevertheless, not all doctors will accept the payment terms.
Of course, the cost will be higher; but you have options for out-of-network health care doctors and hospitals if they agree with the plan’s terms. Some plans may cover the costs of prescription drugs; if not, you may enroll in a Part D Plan.
These plans don’t require choosing a primary care doctor; certain plans have arrangements with a specific network of doctors.
In contrast, out-of-network doctors and hospitals can choose not to treat you in non-emergency situations. For emergencies, hospitals, and other health care doctors may not refuse your treatment.
Special Needs Plans (SNP)
Special Needs Plans restrict enrollment to individuals with specific diseases or disabilities. These plans adjust doctor choices, benefits, and drug formularies to meet best the medical needs of the group they serve.
SNPs have specialists in the diseases or conditions that their members endure. You should get your services and care from doctors and hospitals in your SNP network.
Emergency care for a sudden illness or injury is the exception, as immediate treatment is a must.
- The plan must include Part D
- Members must have a primary care doctor or a care coordinator to assist with health care needs
- Members will need a referral from their doctor before seeing a specialist
- Yearly mammogram screenings, in-network Pap test, and pelvic exams have coverage at least every other year
Beneficiaries with specific disabling or severe conditions may join a Special Needs Plan at any time, once they qualify. Enrolling in an SNP in your service area can be done during the Special Enrollment Period.
Plans should set up the services and providers you need to keep you healthy. You must follow your health care provider’s instructions to ensure optimal results in the treatment of your condition.
For Medicare and Medicaid beneficiaries – your plan should ensure that all the plan doctors you need to use will accept Medicaid.
Part C SNP Beneficiaries residing in an institution – make sure your plan’s providers treat people where you live, to avoid coverage issues.
How to Get Help Understanding All Medicare Advantage Plan Types
Understanding Medicare Advantage Part C and all the supplemental plans that go with it can be a lot of information. MedicareFAQ is here to help you; speak with one of our agents; they commit to answering your questions.
If you need help further understanding the plan you're researching, we can assist in finding the best plan options for your healthcare needs.
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