Medicare Advantage Plans

Medicare Advantage Plans

What is Medicare Advantage?
Medicare Advantage plans are plans offered by a private companies that have contract with Medicare for providing beneficiaries with all Medicare Part A and Part B benefits. Medicare Advantage Plans include HMOs, PPOs, or Private Fee-for-Service Plans and Special Needs Plans. If you are enrolled in a Medicare Advantage Plan, Medicare services will be covered by the plans, and are not paid for under Original Medicare.

Types of plans
Medicare Advantage Plans are offered by private companies and they come in different types that may be classified as:

  • HMOs (health maintenance organizations)
  • PPOs (preferred provider organizations)
  • Private Fee-for-Service Plans
  • Medical Savings Account Plans (MSAs)
  • Medicare Special Needs Plans

HMO Plans
Under HMO plan, you will generally get your health care and services only from the doctors or hospitals in the plan’s network (except for exceptions like emergency care, out-of-area urgent care, or out-of-area dialysis). In a few plans, you can go out-of-network for certain services generally for a higher cost. Generally, HMO plans cover prescription drugs. However just ask and ensure that your plan does. In most cases, you need to get a referral to see a specialist.

PPO Plans
In PPO plans, you will have to use a network of doctors and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost. Prescription drugs are generally allowed. You are not required to get a referral to see a specialist.

PPFS Plans
You can use any approved doctor or hospital that would accept the plan’s payment terms and who agrees to treat you. Not all providers may. If you join a PFFS Plan that has a network, you will usually have to pay more to see out-of-network doctors. If your PFFS Plan does not offer drug coverage, join a Medicare Prescription Drug Plan to get coverage. You do not require a referral to see specialist. Doctors, hospitals, and others may decide on a case-by-case basis not to treat you even if you’ve used them before.

MSA Plans
You can go to any doctor of your choice. Some plans do provide preferred doctors who would be cheaper. Prescription drugs are not generally covered. Medicare MSA Plans have two parts. They are: a high deductible health plan and a specific bank account. Medicare allots the plan a prefixed amount each year for your health care, and the plan deposits a part of this money into your account. The amount deposited will be less than your deductible amount, so that you will have to pay out-of-pocket before your coverage begins.

Special needs plan
You generally must get your care and services from doctors or hospitals in the plan’s network. All special needs plans cover prescription drugs. You need a referral to see a specialist. A plan must limit plan membership to people in one of the following groups a) people who live in certain institutions like a nursing home or those who require nursing care at home, or b) people who are normally eligible for both Medicare and Medicaid, or 3) people who have one or more chronic or disabling conditions like diabetes, congestive heart failure, a mental health condition, or HIV/AIDS.

Who Can Enroll in a Medicare Advantage Plan?
You can generally join a Medicare Advantage Plan if you meet the following conditions: a) You have Part A and Part B, b) you live in the service area of the plan and c) you do not have End-Stage Renal Disease (ESRD) – permanent kidney failure requiring periodic dialysis or a kidney transplant.