If you have Medicare Part A and Part B, you may have the option to enroll in a Medicare Advantage plan. Medicare Advantage (Medicare Part C) is an alternate way to receive your Medicare Part A and Part B coverage. It does not replace your Medicare Part A and Part B coverage.
There are several different kinds of Medicare Advantage plans. These plans are available from private, Medicare-approved insurance companies, and they’re allowed to offer extra benefits beyond Part A and Part B. Some plans include prescription drug coverage, for example. Plans might include routine for dental and vision care and other health-related services not covered by Original Medicare (Part A and Part B).
What types of Medicare Advantage plans may be available where you live?
Here are the major types of Medicare Advantage plans that may be available in your area.
- Medicare Advantage Health Maintenance Organization (HMO)
An HMO has a network of contracted doctors, hospitals, and other health-care professionals who agree to provide services to the plan’s members at a discounted rate. In exchange, the insurance company typically requires plan members to use the network for medical care. Most HMOs won’t cover out-of-network care, except in an emergency or unless the Medicare Advantage plan approves the out-of-network service in advance.
Usually Medicare Advantage HMO plans require you to select a primary care physician (PCP) to coordinate your care and refer you to specialists as needed. HMO plans are often less expensive than other types of Medicare Advantage plans.
- Medicare Advantage HMO Point of Service (HMOPOS)
A variation on the Medicare Advantage HMO, HMOPOS plans add more flexibility to how you access care and coverage. You can usually go outside the plan’s HMO network without referrals. You might pay a higher cost-share for out-of-network services. A Medicare Advantage POS plan may be more expensive than an HMO plan.
- Medicare Advantage Preferred Provider Organization (PPO)*
Similar to HMOs, Medicare Advantage PPOs also have networks of contracted health care providers. Unlike an HMO, however, a Medicare Advantage PPO doesn’t generally require you to select a PCP to provide care and coordinate specialty care through referrals. Also a PPO typically provides benefits even if you go outside the plan’s network, although you might have to pay higher coinsurance or copayments. Medicare Advantage PPOs are more flexible than Medicare Advantage HMOs, but they also are more expensive as a rule.
- Medicare Advantage Special Needs Plans (SNPs)
Medicare Advantage SNPs may take the form of an HMO, POS, or PPO. They are designed for people with Medicare who have particular needs. Medicare Advantage SNPs may be tailored to people who:
- Have severe chronic conditions, such as congestive heart failure or chronic obstructive pulmonary disease
- Live in a long-term care facility
- Are eligible for both Medicare and Medicaid benefits
Medicare Advantage SNPs always include Medicare Part D prescription drug coverage. To enroll in a Medicare Advantage SNP, you must meet the condition the plan is designed to help.
- Medicare Advantage Private Fee-for-Service (PFFS)**
Medicare Advantage PFFS plans generally allow you to see any doctor who agrees to accept plan’s rules and payment terms. Some Medicare Advantage PFFS plans have networks of contracted providers who have agreed to treat any patient who is enrolled in the plan. If you go outside the network for care, first make sure the provider will accept your plan’s terms. Otherwise, you may have to pay all the charges.
- Medical Savings Accounts (MSA)
A Medicare MSA plan is similar to a Health Savings Account (HSA), which you may be familiar with from your years of employment. MSAs have two parts: a high deductible insurance plan and a special savings account. The Medicare Advantage plan deposits a sum of Medicare money into the MSA that pays some, but not all, of the plan’s deductible. You can use this money to pay for Medicare-covered services.
MSA plans don’t generally include prescription drug coverage. If you enroll in a Medicare Advantage MSA plan, you may want to enroll in a stand-alone Medicare Part D prescription drug plan.
When choosing a Medicare Advantage plan, it’s important to review what the plan covers, how much it will cost you, and whether the plan covers your prescriptions. There’s an easy way to find out – just click the Browse Plans button on this page to get started, and click Add Rx Drugs to enter your prescriptions. If you have questions, feel free to contact eHealth’s licensed agents.
A plan’s formulary may change at any time. When required by law, you will receive notice from your plan of changes to the formulary.
*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether the plan will cover an out-of-network service, you or your provider are encouraged to ask for a pre-service organization determination before you receive the service. Please call the plan’s customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.
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