Medicare Advantage plans, aka Medicare Part C, are private health plans offered through insurance companies that contract with Medicare to manage your healthcare. Medicare Advantage plans (MA and MAPD) are alternatives to Original Medicare that provide coverage of Part A, Part B, and usually Part D Prescription Drug coverage.
Medicare Advantage plans can be HMO, PPO, PFFS and SNP plans. These plans typically help limit out-of-pocket costs and may include extra benefits that Original Medicare does not cover like dental, vision, hearing and fitness programs.
Health Maintenance Organization (HMO)
In HMO plans, you must select a primary care physician (PCP) who will oversee and manage your medical care. Referrals are required to see a Specialist and for most diagnostic tests. Medical care in an HMO is provided through a network. You must stay In-Network and use Network providers for benefits to be covered. Exceptions to the In-Network requirement are emergency care, out-of-area urgent care and out-of-area dialysis. It is important that you follow the plan’s rules, like getting prior approval for a most medical service when needed.
Some HMO plans have an out-of-network option for certain services, these are HMOs with a point-of-service plans. Service will usually cost less if you get your care from a network provider. This type of plan is called an HMO with a point-of-service option (HMO-POS).
Preferred Provider Organization (PPO)
A Medicare PPO plan is a type of Medicare Advantage Part C plan offered by a private insurance company. PPO plans have network physicians, health care providers, and healthcare facilities. You pay less if you use physicians, health care providers, and healthcare facilities that are a part of the plan’s network. You pay more if you use physicians, health care providers, and healthcare facilities that are out-of-network. In most cases, you can get your health care from any physician, health care provider, or healthcare facility in a PPO Plan. Out-of-network services will cost more than in-network services.
Most PPO plans cover prescription drugs. If you join a PPO plan that does not offer prescription drug coverage, you cannot sign up for a separate Medicare Part D plan.
PPO plans differ from HMO plans in that in a PPO plan you do not need to select a Primary Care Physician to manage your care and you do not need to get a referral to see a Specialist. Like HMO plans PPO plans have in-network benefits. However, in a PPO plan you can use out-of-network physicians, healthcare providers and healthcare facilities although you will likely pay more.
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 determine how much it will pay physicians, healthcare providers, and healthcare facilities, and how much you must pay when you get care.
If the PFFS plan that has a network, you can see any in-network providers. You can also choose an out-of-network physicians, healthcare providers, and healthcare facilities that accepts the plan’s payment terms. but your costs will usually be lower if you stay in the network. For each service you get, make sure your physicians, healthcare providers and healthcare facilities agree to treat you under the plan, and accept the plan’s payment terms.
Not all PFFS plans include coverage for prescription drugs. If the PFFS plan does not include drug coverage, you can sign up for a separate Medicare Part D Prescription Drug coverage plan.
With all these Medicare Advantage plans, HMO, HMO-POS, PPO and PFFS, you can use out-of-network physicians, healthcare providers and healthcare facilities in an emergency.
Special Needs Plans (SNP)
Medicare SNPs are Medicare Advantage plans designed for and limited to people with specific diseases, certain health care needs, or limited incomes. SNPs tailor their benefits, provider choices, and covered drugs to meet the needs of the specific group they serve.
SNPs require you to have a primary care physician (PCP) who will oversee and manage your medical care. Referrals are required to see a Specialist and for most diagnostic tests. In a SNP plan you are required to use in-network providers except for emergency care, out-of-area urgent care and out-of-area dialysis.