Types of Medicare Advantage Plans
Medicare HMO
- In most instances, individuals must use network providers. They will need a primary care doctor to provide referrals for specialists when necessary. Services may be more expensive or not covered if they are out of the service area and network providers are not used. Up to a limit, the plan can charge a premium above the monthly Part B premium. Providers must accept HMO payment as payment in full.
Medicare PPO
- Individuals may use network providers, but they may also go out of the network and pay more. Primary care doctors or referrals for specialists are not generally required. The plan can charge a premium above the monthly Part B premium, within certain limits.
Private Fee for Service
- Individuals may usually go to any physician or hospital willing to provide care and accept the plan’s payment. There is often a co-payment. Depending on the plan, the provider may be able to charge more than the plan’s reimbursement amount for services, which means you will incur higher costs. The plan can charge a premium above the monthly Part B premium. It is important to check with the company offering the plan about service payments and premiums.
Medicare Special Needs Plans
- These plans are specially designed for individuals with certain chronic conditions or other special health care needs. They provide all Part A and B services, as well as Medicare Prescription Drug coverage (Medicare Part D). They often provide additional services and have lower co-payments than Original Medicare. They often have a care coordinator to develop a care plan for the individual and coordinate all of the services involved in the care.
Medicare Medical Savings Account Plans
- Introduced in 2007, these plans are similar to Health Savings Account Plans that are available outside of Medicare. They include two parts. The first is a Medicare Advantage Plan with a high deductible which must be met before the plan will pay for services, and the second is a Medicare Savings Account into that Medicare deposits money which may be used to pay for health care costs.
Medicare Advantage Plans vary widely in services offered, provider requirements, and premium costs. It is important to look closely at the details of any plan you are considering, paying close attention to what it covers and its costs. Note that many of Medicare Advantage Programs include prescription drug coverage as part of the premium. If it is included in a Medicare Advantage Plan, in most circumstances, individuals must obtain their Medicare Prescription Drug coverage through the Medicare Advantage Plan. If they purchase stand alone Medicare Part D coverage, their enrollment in the Medicare Advantage Plan will be discontinued. For any plans that do not include prescription drug coverage, individuals may purchase a stand-alone Medicare Part D Plan. The new prescription drug coverage is discussed in the next section of this guide.
It is often helpful to consult with an expert when making these decisions. For information about which Medicare Advantage Plans may be available in your loved one’s area or to compare plans, you can call Medicare at 1-800-633-4227 or visit www.medicare.gov.
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