What are Medicare Advantage Plans?
A Medicare Advantage Plan is another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-approved private companies that must follow rules set by Medicare.
Most Medicare Advantage Plans include drug coverage (Part D). In many cases, you’ll need to use health care providers who participate in the plan’s network and service area for the lowest costs. These plans set a limit on what you’ll have to pay out-of-pocket each year for covered services, to help protect you from unexpected costs. Some plans offer out-of-network coverage, but sometimes at a higher cost.
Remember, you must use the card from your Medicare Advantage Plan to get your Medicare-covered services. Keep your red, white, and blue Medicare card in a safe place because you’ll need it if you ever switch back to Original Medicare. If you join a Medicare Advantage Plan, you’ll still have Medicare, but you’ll get most of your Part A and Part B coverage from your Medicare Advantage Plan, not Original Medicare.
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What do Medicare Advantage Plans cover?
Medicare Advantage Plans cover almost all Medicare Part A and Part B benefits. Plans must cover all emergency and urgent care, and almost all medically necessary services Original Medicare covers. However, if you’re in a Medicare Advantage Plan, Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies. Some Medicare Advantage Plans offer prescription coverage.
Medicare Advantage Plans & other options Plans can offer extra benefits Most Medicare Advantage Plans offer coverage for things Original Medicare doesn’t cover, like some vision, hearing, dental, and fitness programs (like gym memberships or discounts). Plans can also choose to cover even more benefits. For example, some plans may offer coverage for services like transportation to doctor visits, over-the-counter drugs, and services that promote your health and wellness.
Plans can also tailor their benefit packages to offer these benefits to certain chronically ill enrollees. These packages will provide benefits customized to treat specific conditions. Check with the plan before you enroll to see what benefits it offers, if you might qualify, and if there are any limitations.
What are the different types of Medicare Advantage Plans?
Health Maintenance Organization (HMO) plan
Can I get my health care from any doctor, other health care provider, or hospital?
No. You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except for emergency care, out-of-area urgent care, or temporary out-of-area dialysis, which is covered whether it’s provided in the plan’s network or outside the plan’s network). However, some HMO plans, known as HMO Point-of-Service (HMOPOS) plans, offer an out-of-network benefit.
Do I need to choose a primary care doctor?
In most cases, yes. Do I have to get a referral to see a specialist? In most cases, yes. Certain services, like yearly screening mammograms, don’t require a referral.
Do these plans cover prescription drugs?
In most cases, yes. If you want Medicare drug coverage, you must join an HMO plan that offers drug coverage.
What else do I need to know about this type of plan?
Medical Savings Account (MSA) plan
Can I get my health care from any doctor, other health care provider, or hospital?
Yes. MSA plans don’t always have a network of doctors, other health care providers, and hospitals.
What else do I need to know about this type of plan?
The plan deposits money into a special savings account. The amount of the deposit varies by plan. You can use this money to pay your Medicare-covered health care costs before you meet the deductible. Money left in your account at the end of the year stays there. If you keep your plan the following year, your plan will add any new deposits to the amount left over.
Do these plans cover prescription drugs?
No. If you join a Medicare MSA plan and need drug coverage, you’ll have to join a separate Medicare drug plan.
Do I need to choose a primary care doctor?
No.
Do I have to get a referral to see a specialist?
No.
Preferred Provider Organization (PPO) plan
Can I get my health care from any doctor, other health care provider, or hospital?
Yes. PPO plans have network doctors, specialists, hospitals, and other health care providers you can use, but you can also use out-of-network providers for covered services, usually for a higher cost. You’re always covered for emergency and urgent care.
What else do I need to know about this type of plan?
Do these plans cover prescription drugs?
In most cases, yes. If you want Medicare drug coverage, you must join a PPO plan that offers drug coverage. If you join a PPO plan without drug coverage, you can’t join a separate Medicare drug plan.
Do I need to choose a primary care doctor?
No.
Do I have to get a referral to see a specialist?
In most cases, no. But if you use plan specialists (in-network), your costs for covered services will usually be lower than if you use non-plan specialists (out-of-network).
Private Fee-for-Service (PFFS) plan
Can I get my health care from any doctor, other health care provider, or hospital?
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. 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 you may pay more.
What else do I need to know about this type of plan?
The plan decides how much you pay for services. The plan will tell you about your cost sharing in the “Annual Notice of Change” and “Evidence of Coverage” documents that it sends each year.
Do these plans cover prescription drugs?
Sometimes. If your PFFS plan doesn’t offer drug coverage, you can join a separate Medicare drug plan to get coverage.
Do I need to choose a primary care doctor?
No.
Do I have to get a referral to see a specialist?
No.
Special Needs Plan (SNP)
An SNP provides benefits and services to people with specific diseases, certain health care needs, or limited incomes. SNPs tailor their benefits, provider choices, and list of drugs (formularies) to best meet the specific needs of the groups they serve.
Can I get my health care from any doctor, other health care provider, or hospital?
Some SNPs cover services out-of-network and some don’t. Check with the plan to see if they cover services out-of-network, and if so, how it affects your costs.
What else do I need to know about this type of plan?
These groups are eligible to enroll in an SNP:
Do these plans cover prescription drugs?
All SNPs must provide Medicare drug coverage.
Do I need to choose a primary care doctor?
yes.
Do I have to get a referral to see a specialist?
In most cases, yes. Certain services, like yearly screening mammograms, don’t require a referral.
Things to know about Medicare Advantage
How do I sign up for Medicare Advantage?
The Center for Medicare Services requires a scope of appointment form to be filled out and returned PRIOR to receiving any quote about coverage.