Medicare Advantage plans: What you need to know

By Home Media

Learn more about what Medicare Advantage plans are, if you’re eligible to join a plan, and why they might be the right fit for your healthcare needs.

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Key Takeaways:

• HMO plans don’t usually offer emergency care, out-of-area urgent care or out-of-area dialysis.

• With Medicare PPO, you don’t have to choose a primary care doctor or get a referral to see a specialist. 

• Original Medicare (Parts A and B) won’t pay for your health care while you’re in a PFFS plan.

• A SNP is a Medicare Advantage plan that limits its membership to people with specific diseases or characteristics. You must get your care and services from doctors or hospitals in the SNP network.

• A medical savings account (MSA) is intended to help self-employed people and employees of certain small businesses save for and pay for their medical expenses not covered by health insurance.

What are Medicare Advantage plans?

Medicare Advantage plans, also known as Medicare Part C, offer a combination of Medicare parts and numerous health services including hearing, dental, vision and prescription drug coverage.

Even though Medicare Advantage is run by private companies, there are many federal protections built into it. For example, Medicare Advantage plans are required to cover everything that Original Medicare covers.

Am I eligible to join a Medicare Advantage plan?

You are eligible to join a Medicare Advantage plan if:

• You have Medicare Part A and Part B

• You live in the service area of the plan you want to join 

• You don’t have end-stage renal disease (ESRD)

There are several types of Medicare Advantage plans from which to choose. Note that each plan has different rules for how you get services, including:\

• Whether you need a referral to see a specialist

• If you have to go to doctors, facilities or suppliers that belong to the plan for non-emergency or non-urgent care

Those and other rules can change each year, so be certain to review your plan annually. If you are ready to discuss your eligibility or want to understand what plans are available in your area, you can dial 214-817-3545 to speak with a licensed insurance agent or you can request a free quote from MedicareExpertUSA.com.

Here are the most common Medicare Advantage plans: 

• Health Maintenance Organization (HMO) plans 

• Preferred Provider Organization (PPO) plans

• Private Fee-for-Service (PFFS) plans

• Special Needs Plans (SNPs)

Health Maintenance Organization (HMO) plans

With HMO plans, you have to get your care and services from providers in the plan’s network. In most cases, prescription drugs are covered. You will need to select a primary care doctor under this plan. If you need to see a specialist, your primary care doctor will give you a referral.

However, certain services, like annual mammograms, don’t require a referral. Be mindful that HMO plans usually don’t offer the following care and services:

• Emergency care

• Out-of-area urgent care

• Out-of-area dialysis

With some HMO plans, you may be able to go out of network for certain services. However, you will most likely have to pay the full cost of the service for going out of the plan’s network.

Medicare Preferred Provider Organization (PPO) plans

A PPO is a Medicare Advantage plan that also has a network of doctors, other health care providers and hospitals. Just like HMO plans, you pay less if you use doctors, hospitals and other health care providers that belong to the plan’s network. 

However, with Medicare PPO, you don’t have to choose a primary care doctor or get a referral to see a specialist. Also, like HMO plans, in most cases prescription drugs are covered in PPO plans. However, be certain to ask if the plan offers Medicare drug coverage. Remember, if you join a PPO plan that doesn’t offer prescription drug coverage, you can’t join a Medicare prescription drug plan (Part D).

Private Fee-for-Service (PFFS) plans

A PFFS plan is a Medicare Advantage plan that determines how much it will pay doctors, other healthcare providers and hospitals for your care, and how much you must pay when you get care. You don’t have to choose a primary doctor or get a referral to see a specialist in PFFS plans. 

If you decide to join a PFFS plan that has a network, you can use any of the network providers who have agreed to always treat PFFS plan members. You can also choose an out-of-network doctor, hospital or other provider who accepts the PFFS plan’s terms, but your costs will usually be higher. Remember that Original Medicare (Parts A and B) won’t pay for your health care while you’re in the PFFS plan.

Be sure to check with the PFFS plan to see if prescription drugs are covered. If it doesn’t offer drug coverage, you can join a Medicare prescription drug plan (Part D) to get coverage.

Here’s more important information on the PFFS plan:

• 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

• 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

• Be advised that your provider can choose at each visit whether to accept your plan’s terms and conditions of payment

• 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

Special Needs Plans (SNPs)

A SNP is a Medicare Advantage plan that limits its membership to people with specific diseases or characteristics. With Medicare SNPs, you must get your care and services from doctors or hospitals in the SNP network. 

SNPs do provide Medicare prescription drug coverage. Medicare SNPs usually have specialists in the diseases or conditions that affect their members. As a result, SNPs usually require you to have a primary care doctor and a referral to see a specialist, except for services like mammograms or pap and pelvic exams. Or, the plan may require you to have a care coordinator. A care coordinator is someone who helps make sure people get the right care and information.

The only time you do not need to get your care and services from doctors or hospitals in the Medicare SNP network is when you are in need of emergency or urgent care because of a sudden illness or injury, or if you have end-stage renal disease and need out-of-area dialysis.

You can join a Medicare SNP if the following applies to you: You have Medicare Part A (hospital insurance) and Medicare Part B (medical insurance)

• You live in the plan’s service area

• You meet the plan’s eligibility requirements to include one of these severe and chronic conditions:

  • Chronic alcohol and other dependencies

  • Autoimmune disorders

  • Cancer (excluding pre-cancer conditions)

  • Cardiovascular disorders

  • Chronic heart failure

  • Diabetes mellitus

  • End-stage liver disease

  • End-stage renal disease (ESRD) requiring dialysis (any mode of dialysis)

  • Severe hematologic disorders

  • HIV/AIDS

  • Chronic lung disorders

  • Chronic and disabling mental health conditions

  • Neurologic disorders

  • Stroke

Institutional SNP (I-SNP): You live in an institution (like a nursing home), or you require nursing care at home

Dual Eligible SNP (D-SNP): You have both Medicare and Medicaid

You can also find less common types of Medicare Advantage plans like the Medicare Medical Savings Account (MSA) plan.

Medicare Medical Savings Account (MSA) plans

Similar to an individual retirement account (IRA), a medical savings account (MSA) is intended to help self-employed people and employees of certain small businesses to save for and pay for their medical expenses that are not covered by health insurance.

Medicare MSA plans combine a high-deductible insurance plan with a medical savings account you can use to pay for your health care costs. There are two parts to the MSA plan:

1. High-deductible health plan: The first part is a special type of high-deductible Medicare Advantage plan. The plan will only begin to cover your costs once you meet a high yearly deductible, which varies by plan.

2. Medical Savings Account (MSA): The second part is a special type of savings account. The Medicare MSA plan deposits money into your account. You can use money from this savings account to pay your health care costs before you meet the deductible.

Medicare MSA plans cover most of the Medicare services that all Medicare Advantage plans cover with the exception of Medicare Part D prescription drugs. You will have to join a Medicare prescription drug plan since it’s not included in the MSA plans. Additionally, some Medicare MSA plans may also cover extra benefits for an extra cost including:

• Dental

• Vision

• Long-term care not covered by Medicare

Drug coverage in Medicare Advantage plans

Remember, most Medicare Advantage plans include prescription drug coverage (Part D). Should you choose, you can join a separate Medicare prescription drug plan with certain types of plans that:

• Can’t offer drug coverage (like Medicare Medical Savings Account plans)

• Choose not to offer drug coverage (like some Private Fee-for-Service plans)

You’ll be disenrolled from your Medicare Advantage plan and returned to Original Medicare if both of these apply:

• You’re in a Medicare Advantage HMO or PPO

• You join a separate Medicare prescription drug plan

Not all Medicare Advantage plans work the same way. Before you join, take the time to find and compare Medicare health plans in your area.