There are several different types of Medicare Advantage plans. Below is an overview of each one. Not every type of plan is available in every service area. To find out which plans are in your area you can check with your Medicare Pathways insurance agent. These plans are not the same as Original Medicare or Medigap.
• Preferred Provider Organization (PPO Plans)
• Private Fee-for-Service (PFFS Plans)
• Special Needs Plans (SNP)
• Medical Savings Accounts (MSA Plans)
Health Maintenance Organization (HMO Medicare Advantage Plans)
These are types of Medicare Advantage plan that usually offer low premiums but may not be flexible on using non-network providers. HMO Medicare Advantage Plans are usually available in densely populated areas. Out of the different type of Medicare Advantage plans (with the exception on SNP Plans) the Medicare Advantage HMO usually offers the lowest cost sharing and premiums for Medicare beneficiaries if you stay in network. However, HMO Medicare Advantage Plans also have the most restrictions or rules a member must follow. For example, a member must use the plan’s network of doctors, hospitals and providers to receive care except for in emergencies. You also may need to select a primary care doctor to manage your health care. You may need a referral from your primary care doctor if you want or need to see a specialist.
Some HMO Medicare Advantage Plans offer a Point of Service option (HMO-POS) that allow a member to get some services out-of-network for a higher co-pay or co-insurance. Unless your HMO Advantage Plan has this option you will be responsible for any non-emergency out-of -network care.
HMO Medicare Advantage Plans are great options for Medicare beneficiaries that want keep their premium and cost sharing expense low and don’t mind using network providers. You should always check to see if your primary care doctor is in the plan’s network. If they are not you may want to consider selecting a different doctor or a different type of plan.
Preferred Provider Organization (PPO Medicare Advantage Plans)
These are types of Medicare Advantage plans that offer more flexibility than an HMO but may cost little more. With a Medicare Advantage PPO you can generally get care from any U.S. provider that accepts Medicare. You will pay less if you choose to use one of the plans preferred providers. This is sometimes called the PPO Network. If you want to go to a Medicare accepting doctor or provider that is not in the preferred provider network you can do so. However, if you go out of the preferred provider network you may pay more cost sharing.
Medicare Advantage PPO Plans do not require a referral if you want to see a specialist or go out of network. Members are always encouraged to check with the plan to make sure services are covered and medically necessary. Medicare Advantage PPO Plans can usually offer more benefits than original Medicare, but you may have pay more.
PPO Medicare Advantage Plans are great options for Medicare beneficiaries that want more flexibility than an HMO provides. It may be a good fit if most of your providers are in network or you don’t mind paying a little more to use doctors and providers out of network.
Private-Fee-For Service (PFFS Medicare Advantage Plans)
These are types of Medicare Advantage Plans that offer the most flexibility but could cost more than the HMO or PPO Plans. PFFS Plan members may receive covered services from any U.S. doctor or provider that participates in Medicare and agrees to the plans terms and conditions. Some PFFS Plans do have network providers as well. If you have a PFFS Plan with a network of providers you may pay more to go out of network.
Non-Networks providers may decide whether to treat a PFFS Plan member on a visit by visit or case by case basis. PFFS Plan members must inform providers before receiving services that they are PFFS plan members so the non-network providers can decide whether to accept the plan’s terms and conditions. Medicare Advantage PFFS Plans are not the same as original Medicare or a Medigap Plan.
PFFS Medicare Advantage Plans are great options for Medicare beneficiaries that want the most provider flexibility. It may be an option to consider if your providers agree to accept the plans terms and conditions or you don’t mind finding a provider who does.
Special Needs Plans (SNP Medicare Advantage Plans)
These are types of Medicare Advantage Plans for certain groups of Medicare beneficiaries. These plans combine a Medicare Advantage health plan and a Medicare Part D Drug plan built into one. This allows the Plan to tailor the drug and healthcare benefits to the special needs group.
Different types of SNP plans include:
Dual Eligible SNP- These are Medicare Advantage Special Needs Plans designed for someone who is dually on Medicare and Medicaid at the same time.
Chronic Care SNP- These are Medicare Advantage Special Needs Plans designed for Medicare beneficiaries with certain severe or disabling chronic conditions.
Institutional SNP- These are Medicare Advantage Special Needs Plans designed for Medicare beneficiaries in long-term care facilities or that require an institutional level of care.
Special Needs Medicare Advantage Plans may be an appropriate options for Medicare beneficiaries that are eligible for one of the SNP categories.
Medicare Advantage Medical Savings Account (MSA Plans)
These are types of Medicare advantage plans that combine a high deductible health plan with a savings account. On these types of plans Medicare make a contribution to the Medicare beneficiary’s savings account and then the beneficiary uses this account to pay for medical expenses. The beneficiary of responsible for medical costs until the annual deductible is reached. In 2012, the maximum deductible for Medicare Advantage MSA plans is $10,600. If you choose an MSA Plan you will have to get a separate Medicare Part D Drug Card as the MSA plans are not allowed to cover Medicare Part D. Currently, there are a limited number of plans that offer MSA Plans and it may be difficult to find one in your service area.
Medicare Advantage Medical Savings Account Plans may be an appropriate options for Medicare beneficiaries that have they MSA option in their area and don’t mind paying for their medical cost prior to meeting the deductible.
Which Medicare Advantage Plan Option Should I Choose?
Your Medicare Pathways agent can do a personal Needs Assessment and recommend a plan type in your area based on your personal situation, likes and dislikes. To speak with a Medicare Pathways Agent please call 1-866-466-9118.