Types of Medicare Advantage Plans

Preferred Provider Organization (PPO) Plans

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 pay more if you use doctors, hospitals, and providers outside of the network.

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.

Prescription drugs are covered in  most PPO Plans. Ask the plan or broker. 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).

Because certain providers are “preferred,” you can save money by using them. A PPO Plan isn’t the same as Original Medicare or a Medicare Supplement Insurance (Medigap) policy. It usually offers extra benefits than Original Medicare, but you may have to pay extra for these benefits. Check with the plan or broker for more information.

Health Maintenance Organization (HMO) Plans

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

• Emergency Care
• Out-of-area urgent care
• Out-of-area dialysis

In some plans, you may be able to go out-of-network for certain services. But, it usually costs less if you get your care from a network provider. This is called an HMO with a point-of-service (POS) option. In most cases, prescription drugs are covered in HMO Plans. Ask the plan or your broker. If you want Medicare drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage. Additionally, you need to choose a primary care doctor for your HMO plan.

To see specialists, you will have to get a referral in HMO plans. Certain services, like yearly screening mammograms don’t require a referral. 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.

Special Needs Plans (SNPs)

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.

Generally, you must get your care and services from doctors or hospitals in the Medicare SNP network, except:

• Emergency or urgent care, like care you get for a sudden illness or injury that needs medical care right away
• If you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis

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

Are prescription drugs covered?

All SNPs must provide Medicare prescription drug coverage.

Do I need to choose a primary care doctor?

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.

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

In most cases, you have to get a referral to see a specialist in SNPs. Certain services don’t require a referral, like these:

• Yearly screening mammograms
• An in-network pap test and pelvic exam (covered at least every other year)

A plan must limit membership to these groups: 1) people who live in certain institutions (like a nursing home) or who 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. You can join a SNP at any time.

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.
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. Learn more about how SNPs work by clicking here.

Private Fee-for-Service (PFFS) Plans

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.

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 network, you can also see any of the network providers who have agreed to always treat plan members. You can also choose an out-of-network doctor, hospital, or other provider, who accepts the plan’s terms, but your costs will usually be lower if you stay in the network. 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. It’s important to check with your doctor beforehand to make sure they will take your plan.

Prescription drugs may be covered under a PFFS. If your PFFS Plan doesn’t offer drug coverage, you can join a Medicare drug plan (Part D) to get coverage. Additionally, you don’t need to choose a primary care doctor in a PFFS plan and you don’t have to get a referral to see a specialist.

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. You only need to pay the copayment or coinsurance amount allowed by the plan for the type(s) of service you get at the time of the service.

Point of Service (POS) Plans

In general, a Point of Service (POS) health insurance plan provides access to health care services at a lower overall cost, but with fewer choices. Plans may vary, but in general, POS plans are considered a combination of HMO and PPO plans. You can access care from in-network or out-of-network providers and facilities, but your level of coverage will be better when you stay in-network. If you have a point of service plan, depending on your specific plan design, you may be required to get referrals from your primary care provider (PCP).

The term “point of service” refers to where and from what provider you receive services. Your coverage varies depending on whether you see a provider who’s in- or out-of-network and if you’ve received a referral, if required by your plan.

Like an HMO, you start by selecting a Primary Care Provider (PCP) to help coordinate and manage your health care needs. Your costs for care will be lower if you see in-network providers. Like a PPO, you have choices about where to receive care. Your PCP may refer you to in-network specialists, if your particular plan requires it. You are also free to see out-of-network specialists, without a referral, but you could pay more for that flexibility.

POS insurance works best if you’re willing to follow the terms of this type of health plan. If you’re comfortable selecting a PCP to manage your care, this plan may be right for you.

Remember, even though a POS plan might have an overall lower cost, you may pay higher costs if you need to see a provider that’s outside your plan’s network. It’s worth checking to make sure the providers you normally see are in-network for the plan you’re choosing.