Understanding Each Type Of Medicare Advantages Plan And Their Work

People can select a plan from a lot of Medicare Advantage plans. The best thing about Medicare Advantage is that many plan options mirror what you will receive from an employer. Therefore, when people opt for a Medicare Advantage plan, there are many options to choose from. In 2020, 3,148 plans were available, offering people in most states a lot of plans to select from. Always consider what plans are best for you and how to select which option is suitable.

Health Maintenance Organizations (HMOs)

A Medicare Advantage health maintenance organization (HMO) provides health coverage within a network of providers. Consumers can only access doctors and facilities that contract with specific HMOs if they choose Medicare HMO. Therefore, except in some emergencies, you should seek care from one of the network’s preferred providers. Some crucial things to know about these plans include:

  • Many HMOs cover prescription drugs
  • There is a requirement to select a primary care provider (PCP). If a consumer needs extra care, the primary care provider can refer the consumer to a specialist.
  • People must follow all the terms and conditions of the plan, and even HMOs cover a broad range of services.
  • In many cases, HMOs’ plan is not covered outside of their network, even after a consumer meets their deductible. However, there can be covered for urgent care, emergency, and care while traveling outside an area that HMO covers.

A few HMOs give a point-of-service (POS) option, which offers to visit doctors outside the plan’s network. But you should pay extra cost to get this service. In addition, HMOs may limit when people utilize them. For example, a few HMOs provide prescription drug coverage in Medicare Part D, while others don’t. If you have a plan that doesn’t offer Part D coverage, you usually can’t receive other Part D coverage outside of the plan. 

Medicare Advantage of PPO

A Medicare Advantage preferred provider organization (PPO) gives a special discount for selecting providers within the plan’s preferred provider network. In a few cases, there may not be covered by other providers until consumer reach their deductible. In other cases, the Copay may be high enough to select an out-of-network provider. Some other significant aspects of PPO schemes include:

  • Providers who accept Medicare, a consumer can seek care from them. However, the costs may be higher if you choose an out-of-network provider.
  • Coverage of prescription drugs is come under in most Medicare Advantage PPO plans.
  • If you buy PPO Medicare Plans, there is no need to choose a PCP, and you don’t need a referral to meet a doctor or specialist.
  • You may have coverage for many services not covered by Original Medicare. However, the charges for these services may be higher.

Medicare Advantage SNP 

The Medicare Advantage Special Needs Plan (SNP) caters to a group of people with particular needs. For people who have related or similar disabilities, such as autoimmune disease, dementia or diabetes, etc., these plans usually work with them. If there is no emergency, like requiring dialysis, end-stage kidney disease, or requiring a transplant outside the coverage area or while traveling outside the state that plans cover and immediate care required, the consumer should seek care from in-network providers. 

  • Covering prescription drugs, SNPs are required.
  • To get a referral to meet a specialist or doctor, most plans require choosing PCP.
  • Special Needs Plan offers care for the symptoms or disease the plan covers.
  • A few plans are limited to consumers who live in institutional settings, like people in memory care services.

The main goal of SNP is to provide related healthcare services to those who can benefit most from the specialized expertise and focused care management of plan providers. All SNPs should provide Medicare prescription drug coverage. People can get more benefits than Original Medicare. Medicare SNPs are designed for certain people. This includes:

  1. C-SNPs: for people with specific disabling and chronic conditions
  2. D-SNPs: for people who are eligible for both full Medi-Cal (‘’dual eligible”) and Medicare
  3. I-SNPs: For people in specific institutions such as a nursing home or a person who lives at home but needs the same care as a patient in a nursing home.

Medicare Advantages PPFS

A Medicare Advantage private fee-for-service (PFFS) plan is private insurance. However, these plans are different from HMO and PPO plans. In PPFs, different plans have different rules, varying from plan to plan. In addition, every plan has its own Copays and reimbursement rates. 

  • PFFS plans generally cover prescription drugs
  • There is no need to get a referral or select a PCP before meeting a doctor
  • There is significant variability from one plan to another. Some plans have a preferred provider network that offers significant discounts. On the other hand, some other permits you to choose any provider. People can go to any provider who accepts Medicare. However, the cost can change and vary depending on the plan’s rules.
  • A provider should agree to accept the payment terms and facilitate the consumer under the plan. However, a provider may choose not to treat consumers even if they have seen it before.

Other Medicare Advantage Plan options

Some Medicare Advantage plans are not well-known as others. These plans may not be accessible to all beneficiaries. 

  • HMO-POS plans Health maintenance organization (HMO-POS) plans. There are many similarities between HMOPOS and HMOs. But provide some out-of-network services, generally at a higher cost. They may be a good alternative for those who prefer HMOs but also have specialists.
  • Medical saving account (MSA) plans: These plans have higher deductibles than Medicare Advantage or Original Medicare. These plans offer to the policyholder to open a saving account in their bank to get help funding medical charges.

Final Words

Medicare Advantage plans are an alternative to the Original fee-for-service. These plans are sponsored by Medicare. Private insurance companies charge to give health services to a policyholder who enrolls in these plans, and Medicare pays all the charges. In addition, some employer and retiree plans offer health coverage through Medical Advantage plans. 

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