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?
If your doctor or other health care provider leaves the plan’s network, your plan will notify you. You may choose another doctor in the plan’s network.
If you get health care outside the plan’s network, you may have to pay the full cost.
- It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.
- Check with the plan for more information
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.
- MSA plans don’t charge a premium, but you must continue to pay your Part B premium.
- Some plans may cover extra benefits, like dental, vision and hearing. You may pay a premium if you use these services
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?
- Because certain providers are “preferred,” you can save money by using them.
- A PPO plan isn’t the same as Original Medicare or Medicare Supplement Insurance (Medigap).
- It usually offers extra benefits than Original Medicare, but you may have to pay extra for these benefits.
- Check with the plan for more information.
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.
- Some PFFS plans contract with a network of providers who agree to always treat you, even if you’ve never seen them before.
- Out-of-network doctors, hospitals, and other providers may decide not to treat you, even if you’ve seen them before.
- In a medical emergency, doctors, hospitals, and other providers must treat you.
- For each service you get, make sure to show your plan member card before you get treated.
- Check with the plan for more information
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:
- People who live in certain institutions (like nursing homes) or who require nursing care at home (also called an “Institutional SNP” or I-SNP).
- People who are eligible for both Medicare and Medicaid (also called a “Dual Eligible SNP” or D-SNP). D-SNPs contract with your state Medicaid program to help coordinate your Medicare and Medicaid benefits.
- People who have specific severe or disabling chronic conditions (like diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia) (also called a “Chronic condition SNP” or C-SNP). Plans may further limit membership.
- A SNP provides benefits targeted to its members’ special needs, including care coordination services.
- Visit Medicare.gov/plan-compare to find and compare Medicare Advantage Plans and see if SNPs are available in your area. Select “Add Special Needs Plans” if this option is available when you view plans.
- Check with the plan for more information. SNP SECTION 4: M
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
Medicare Advantage Plans must follow Medicare’s rules Medicare pays a fixed amount for your coverage each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare.
However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you must go to doctors, facilities, or suppliers that belong to the plan’s network for non-emergency or non-urgent care).
These rules can change each year. The plan must notify you about any changes before the start of the next enrollment year.
- Remember, you have the option each year to keep your current plan, choose a different plan, or switch to Original Medicare.
- Providers can join or leave a plan’s provider network anytime during the year. Your plan can also change the providers in the network anytime during the year. If this happens, you won’t be able to change plans but you can choose a new provider.
- You generally can’t change plans during the year. Even though the network of providers may change during the year, the plan must still give you access to qualified doctors and specialists. Your plan will make a good faith effort to give you at least 30 days’ notice that your provider is leaving your plan so you have time to choose a new provider. Your plan will also help you choose a new provider to continue managing your health care needs.
- A Medicare Advantage plan only covers one person. Spouses must enroll in a separate Advantage Plan.
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.