Medicare Advantage Plans are also known as MAPD plans, MA plans, and Part C. Traditionally people usually get their Medicare coverage through a government-run program called Original Medicare. If you chose a different method, another option for you would be the Medicare Advantage Plans, accessible from private insurance companies in contract with Medicare. Depending on where you live, you may enroll in a Medicare Advantage Plan offering one or more of the following health care such as HMO, PPO, PFFS, or MSA.

Original Medicare

If you choose coverage under the traditional fee-for-service Medicare program, you can get care from any doctor or hospital you want and receive coverage for your care anywhere in the country. However, traditional Medicare has high cost-sharing requirements and does not cover the costs of certain services. To help pay for uncovered benefits and to help with Medicare’s cost-sharing requirements, many people in the traditional Medicare program have supplemental insurance, known as Medicare Supplements or Medigap Plans (these plans fill in the gaps that Medicare does not cover. Unlike Medicare Part C and Part D, these plans are not part of the government-run Medicare program).

Medicare Advantage Plans

Medicare HMOs

Medicare Advantage HMOs (Health Maintenance Organization) cover the same doctor and hospital services as the original Medicare program, but out-of-pocket costs for these services are usually different. All Medicare Advantage Plans must supply the same coverage as Part A and Part B (with exemption from hospice care) and Original Medicare but it still varies by the plan, and for example, some HMOs cover for SilverSneakers, Eye Glasses, Hearing, Dental, etc. These aren’t covered by the traditional Medicare program. They may charge a premium that you would need to pay besides the Part B monthly premium.

You should know Medicare HMO enrollees can only use doctors, hospitals, and other providers in the HMO’s network. For an additional fee, some HMOs offer point-of-service (POS) or benefits that partially cover care received outside the network.

If you join a Medicare HMO, you will usually have to select a primary care doctor responsible for deciding when you should see a specialist and which specialist you should see.

Most HMOs will not pay for unauthorized visits to specialists in the plan, providers outside the HMO’s network, or for non-emergency care outside the HMO’s service area.

Medicare PPOs

Medicare Advantage PPOs (Preferred Provider Organizations) are private health plans, much like Medicare HMOs. You pay less if you use health care providers such as doctors, hospitals, and others that belong to the plan’s network. HMOs and PPOs differ in two key ways:

  1. Medicare PPOs cover some costs of your care if you use doctors and hospitals outside the network.
  2. Medicare PPOs generally do not require that you see a primary care physician before going to a specialist.

Regional PPOs became available under Medicare in 2006. These plans are similar to local Medicare PPOs, but serve a larger geographic area (either a single state or multi-state area) and must offer the same premiums, benefits, and cost-sharing requirements to all beneficiaries in the region. Regional Medicare PPOs offer all Medicare benefits, including a prescription drug benefit. These plans often have a single deductible for physician and hospital services and a yearly out-of-pocket limit on the cost-sharing for benefits under Medicare Parts A and B. You have to remember that the out-of-pocket limit will differ depending on the plan you select. Individuals who sign up for a regional or local PPO will typically pay more if you use doctors, hospitals, and providers outside of the network.

Private Fee-for-Service (PFFS) Plans

Medicare PFFS plans differ from Original Medicare or Medigap, they cover Medicare benefits like, doctors, hospitals and other health care providers, the same with Medicare HMOs and PPOs. Private fee-for-service plans do not have a formal network of doctors and hospitals, unlike Medicare HMOs and PPOs. Still, not all doctors and hospitals will treat members of a private fee-for-service plan. If considering enrolling in a private fee-for-service plan, make sure your doctor and hospital will accept the private fee-for-service plan’s payments for services before you enroll. Also, be sure you understand a plan’s benefits and cost-sharing requirements before you enroll because private fee-for-service plans decide how many enrollees pay for Medicare-covered services. They may also charge a higher cost-sharing for certain health care services than the Original Medicare program. PFFS plans are not required to offer the Medicare drug benefit, most do. If you enroll in a private fee-for-service plan without drug coverage, you can also enroll in a Medicare stand-alone prescription drug plan for your drug coverage.

A Medicare Advantage PFFS plan works differently than a Medicare supplement plan. It does not require your provider to agree to accept the plan’s terms and conditions of payment and thus may choose not to treat you, except for emergencies. Your provider may choose not to provide health care services to you if they do not accept the terms and conditions of payment, with an exception during emergencies. And if this happens, you need to find another provider that will accept the payment terms and conditions. Providers can find the plan’s terms and conditions of payment on the plan’s website.

Special Needs Plans (SNPs)

Special needs plans are private plans that provide Medicare benefits, including drug coverage for beneficiaries with specific diseases or characteristics. These include people eligible for both Medicare and Medicaid, those living in certain long-term care facilities (like a nursing home), and those with severe chronic or disabling conditions.

Your care and services from doctors and hospitals must be from a Medicare SNP Network because they have specialists that treat the diseases and conditions that affects their members. You may get care from other doctors, hospitals, or health care providers if you need emergency care or if you have End-Stage Renal Disease (ESRD).

Less Common Types of Medicare Advantage Plans

Medicare MSA Plans

A Medicare Medical Savings Account Plan is a consumer-directed Medicare Advantage plan, it offers a health insurance policy with a high deductible and medical savings account you can use to pay for your health care costs. Medicare makes a deposit to the Medicare MSA that you establish and pays the premium for the Medicare MSA Plan. The money deposited in your Medicare MSA will pay for your medical expenses. Next year’s deposit will be added to your balance, if you don’t use all the money in your Medicare MSA. Money can also be used for non-medical expenses, but that money will be taxed. If you enroll in a Medicare MSA, you must stay in it for a full year.

HMO Point of Service (HMOPOS)

This plan may allow you to get some services out-of-network but for a higher cost.

Medicare Advantage Plans and Prescription Drugs

All companies offering Medicare Advantage plans must offer prescription drug coverage in at least one of their plans. Medicare Advantage plans with drug coverage may vary in their premiums, deductibles, formularies, and cost-sharing, depending on the Medicare Advantage plan you select.

For more information about Medicare Advantage plans, call 1-800-MEDICARE, or get information about Medicare options in your area on the Medicare Personal Plan Finder website.

If you need any help, drop us a call to speak with our friendly licensed insurance agent at 866-445-6683


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