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Medicare FAQs - Types of Medicare Advantage Plans

1.What types of Medicare Advantage plans are available?

  • Health Maintenance Organization Plan (HMO) − Joining an HMO means that, to ensure you pay the lowest price possible, you'll need to see only those providers in your plan's network unless you need emergency or urgent care. If you regularly see a provider not in your plan's network, you'll need to pay full price for those services on your own.

    An HMO requires you to have a Primary Care Physician (PCP) who can perform general checkups and evaluations and refer you to other doctors. You may also need to get a prior authorization from the HMO plan, which means that you or your doctor will need to call the plan to get approval before obtaining treatment. If you do not get a referral from your PCP or prior authorization from the plan, you may need to pay full price at the time you're treated.
  • Preferred Provider Organization Plan (PPO) − If you decide to become a member of a PPO, you can usually go to any doctor or provider in or out of the plan's network, though your copayments will probably be higher if you see someone outside of the network. You do not have to get a referral from a PCP to see another doctor, but your plan may want you to get prior authorization for certain services.
  • Private Fee for Service Plan (PFFS) − Some PFFS plans have a network while others do not. Generally, you can see any healthcare provider in your plan's coverage area as long as the provider is eligible to be paid by Medicare and is willing to accept the PFFS plan's terms of payment. If your PFFS plan has a network, you may pay more to go to the doctor if he or she is out-of-network.

    It is important to know that a doctor or other healthcare provider may choose not to accept a PFFS plan at any time, even if the provider otherwise participates in Medicare. So, before seeking any non-emergency treatment under a PFFS plan, contact your doctors, hospitals and other healthcare providers to make sure they still agree to accept the PFFS plan.
  • Special Needs Plan (SNP) − A SNP is an HMO specifically developed for beneficiaries who are either institutionalized, eligible for both Medicare and Medicaid, or have certain diseases. Although some SNPs do allow everyone to enroll, many only accept individuals who meet their criteria. If a SNP does not allow you to enroll, you will be instructed to find a different plan that will cover you, such as an HMO, PPO or PFFS.
  • Medical Savings Account (MSA) − MSAs are typically high-deductible plans that also include a bank account to be used only for your healthcare expenses. If you decide to join an MSA, your plan will create an account for you and deposit a certain amount of money that it receives from Medicare. When you go to the doctor or get prescription drugs, you'll use money from this account to pay for the expenses until you have reached your deductible. Once you reach your deductible, many plans pay up to 100% of your costs for the rest of the year. For every year you are a member, the MSA plan will make a new deposit into the account.

2.What are the special rules for HMO Medicare Advantage plans?

Primary Care:

  • Participants must choose a primary care physician (PCP)
  • Referrals and prior authorization requirements to deal with
  • Generally, participants must get a referral from the PCP to see other physicians
  • Generally, participants must get prior authorization from the plan to see other providers

Network:

  • Must see plan providers in the network except for emergency and urgently-needed care in the plan network
  • If you see a provider outside of the network, you will have to pay the full cost of the service
  • Some plans may offer a travel benefit, which allows for limited coverage out of the area/out of network
  • Some plans may offer a point-of-service (POS) option that allows members to use out-of-network providers for a higher cost

Part D:

  • Usually has a plan option that covers Part D prescription benefits (called Medicare Advantage prescription drug or MA-PD)
  • If you want drug coverage, it must be purchased through this plan and may not be a free standing Part

Other Benefits:

  • Vary according to plan

3. What special rules apply to Special Needs Plans (SNP)?

Primary Care

  • You must choose a primary care physician (PCP).
  • Referrals and prior authorization requirements to deal with
  • Generally, you must get a referral from the PCP to see other physicians.
  • Generally, you must get prior authorization from the plan to see other providers.

Network

  • You must see plan providers in the network except for emergency and urgently needed care in the plan network.

Part D

  • Must offer Part D prescription benefits
  • If you want drug coverage, it must be purchased through this plan and may not be a freestanding Part D plan.

Other Benefits

  • Other services may be available.

Enrollment Rules

  • Unlike other Medicare Advantage plans, you may join or leave at any time of the year.
  • You must meet plan specific criteria.

4. What are the rules related to Preferred Provider Organization (PPO) plans?

Primary Care

  • You do not need to choose a primary care physician (PCP).

Referrals and Prior Authorization

  • You do not need to get a referral from the PCP to see other physicians.
  • You may need to get a prior authorization from the plan to see other providers.

Network

  • You may see providers who are in or out of the network.
  • If you see a provider outside of the network, you will have to pay a higher cost.

Part D

  • Usually has a plan option that covers Part D prescription benefits (Medicare Advantage-Prescription Drug or MA-PD)
  • If you want drug coverage, it must be purchased through this plan and may not be a freestanding Part D plan.

Other Benefits

  • Other services may be available.

5. What are the benefits of a Private Fee-for-Service (PFFS) plan?

Primary Care

  • You do not need to choose a primary care physician (PCP).

Referrals and Prior Authorization

  • You do not need to get a referral from the PCP to see other physicians.
  • You do not need to get a prior authorization from the plan to see other providers.

Network

Non-Network PFFS:

  • You can see any Medicare approved provider if the provider agrees to the plan's terms and conditions - called "deemed provider."
  • Providers have a choice to accept these terms and conditions.

Limited Network PFFS

  • If certain providers are used, there is lower member cost sharing.
  • If non-network providers are used, non-network PFFS guidelines apply.

Part D

  • May cover Part D prescription benefits
  • If the plan offers prescription drug coverage, it must be purchased through this plan and may not be a free standing Part D.
  • If Part D is not a plan option (integrated Part D coverage), then you have the opportunity to purchase a freestanding Part D plan.

Other Benefits

  • Other services may be available.

6. What are the benefits of a Medicare Medical Savings Account (MSA)?

Cost

  • High deductible plan with significant cost sharing until deductible is met

Benefits

  • Purchase free-standing prescription plan
  • Purchase high deductible plan with additional benefits