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How Each Medicare Advantage Plan Works

by Tracy Finke

When you are choosing the best Medicare Plan, you really need to take the time to go through each option before you make a final decision. Many of the Medicare plans mirror what you would get from an employee. There are a variety of options that depend on your age, location and need. Two years ago, there were 3,148 plans available!

This may be a lot of information to process, but we can help you out. What type of Medicare Advantage Plans is best for you? Below, we’ll explain the plans in more detail in hopes you can find the best one for your individual needs.

Medicare Advantage HMO

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A network of providers offers Medicare Advantage Health Maintenance Organization – also known as HMO. Keep in mind that when you are requesting care, you need to go to one of their providers and nobody else. This however isn’t the case for some emergency situations. When opting for HMO, make sure to check with the provider which emergencies don’t tie you to them.

This is a common plan a lot of enrollees opt for. First of all, you will get prescription drugs with a majority of HMOs. Secondly, you will be required to choose a primary care provider who can later refer you to a specialist if that’s necessary.

As we’ve already said, you will need to be careful not to go outside the network. Even when you cover the deductible, going outside your provider network is allowed only in a few emergencies. To get the full coverage, you need to follow the rules and guidelines of the HMO. If there are some questions, it is best to check with your insurance provider.

Medicare Advantage PPO

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The second Medicare Advantage plan we will mention is the Medicare Advantage preferred provider organization or PPO. This enables enrollees to find the provider within the plan’s preferred provider network and save some money. It could happen that there’s no coverage for other providers until you reach your deductible.

If you decide to go with the provider outside the network, the co-pay can be significantly higher than you thought. It is important to double-check this before you sign a deal.

The PPO insists on using the provider who is in the preferred network. You will receive certain advantages and discounts for doing so. However, it is important to know that you can seek care from any provider that accepts Medicare. In this case, the costs and co-pays will be higher.

Another big reason why PPO is popular among Medicare enrollees is prescription drug coverage. Unlike the HMO, you will not need to find a primary care provider and you will not need a referral in case you have to visit a specialist. Lastly, the PPO is a great plan to fill in the gaps of the original Medicare, but it is not primarily used as such because the fees for these services could be higher.

Medicare Advantage PFFS

Source: medicalnewstoday.com

The next one is Medicare Advantage private fee-for service (PFFS) plan. This is private insurance and it differs a lot from the previous two plans that we’ve mentioned. The rules are different from plan to plan and you need to talk with the provider and see what actually works for you best. Every plan that falls under PFFS comes with specific reimbursement rates and copays and since there are a lot of specifics for every plan, we will just cover the basic characteristics.

The first one is significant variability from plan to plan. There are certain plans that offer major discounts, while some others offer a preferred provider network. But, just like with the other option in this article, no matter which version of the PFFS you select, you can visit any provider that accepts Medicare. Depending on the plan you selected, your copays and fees could vary.

A majority of PFFS plans cover prescription drugs. For those that are seeing a specialist, they will not need a referral. As for the primary care providers, you don’t need to select one.

Medicare Advantage SNP

The final major Advantage plan is Medicare Advantage special needs plan or SNP. This is the plan that is designed for people who require special needs – either have disabilities, or suffer from diseases such as dementia, autoimmune disease or diabetes.

Usually, you are required to go to the selected network provider. There are some cases when you can use an outside healthcare provider including certain emergencies, end-stage renal disease or if you need dialysis outside the coverage area. This makes the SNP more flexible than some other Advantage Plans.

Prescription drugs are included in the plan coverage. Because of the specific diseases, you will need to find a primary care provider and a referral to see a specialist. Depending on the disease you have, you will receive specialist care as a part of the plan.

Other Medicare Advantage Plans Worth Mentioning

Source: medicalnewstoday.com

There are some other plans that are worth mentioning, which may not be as popular or as available. The first one is health maintenance organization point of service or HMOPOS. These are similar to HMOs, but with more flexibility for out-of-network services. There is also a Medical savings account or MSA plan. These plans offer higher deductibles than the original Medicare. Enrollees can open a savings account that they will use for medical costs.

The Bottom Line on Medicare Advantage

Source: forbes.com

We’ve provided you with the general characteristics of every Medicare advantage plan, but it is up to you to find a provider and choose the specific option. Keep in mind that most of these plans have specific uses, and they may not be available in every area. Although providers need to follow the Medicare guides and coverage, pricing is something they determine, so it may be worth checking in with several providers before you enroll.

If you are an eligible Medicare recipient, you can find more details about each Medicare Advantage Plans at MedicareConsumer.com. In addition, you can also ask them for more details about fees and prices regarding each of the Medicare plans too.