Medicare Moment: Types of Medicare Advantage Plans

Types of Medicare Advantage Plans

Medicare Advantage Plans, also known as Part C, fall into different types that set the framework for their benefit structure. Here’s a high-level overview of the most popular plan types:

Health Maintenance Organization (HMO) Plans[1] – These plans generally require that you receive your care from certain providers that are in-network, except for emergency care, out-of-area urgent care, and temporary out-of-area dialysis. Most plans require that you select a primary care doctor, and in most cases, you must have a referral to see a specialist.

Preferred Provider Organization (PPO) Plans[2] – These plans allow you to receive care from out-of-network providers for covered services, but you may pay more. The out-of-network provider must agree to treat you and can’t opt out of Medicare. You are still covered for emergency and urgent care. PPO Plans don’t require you to choose a primary care doctor, and, in most cases, you don’t need a referral to see a specialist.

Private Fee-for-Service (PFFS) Plans[3] - These plans determine how much they will pay providers, and how much you will pay when you receive care. “You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan's payment terms, agrees to treat you, and hasn’t opted out of Medicare…Not all providers will.” These plans don’t require a primary care doctor or specialist referral.

Special Needs Plans (SNPs)[4] –These plans limit membership to people who have specific diseases or characteristics, and tailer their benefits to their needs. SNPs may be set-up like an HMO or PPO, so out-of-network coverage and need for specialist referrals vary by plan. SNPs are required to offer Medicare prescription drug coverage.

Two less common plan types are HMO Point of Service (HMOPOS) Plans and Medicare Medical Savings Account (MSA) Plan[5].

By: Steven Thomas Smith

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