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The different types of Medicare Advantage plans available

different-types-medicare-advantage-plans

HMO – Health Maintenance Organization plans: HMO plans use a network primary care provider to help coordinate care. HMO plans usually only pay for providers in the plan network. Most HMO plans require a referral to a specialist. Your care and services are provided by in-network providers except in emergency care and out of area urgent care.  

  • Networks: Generally, you must use the plan’s network of doctors and hospitals for services you need to be covered, otherwise you will incur out-of-pocket costs.  
  • Emergency Services: You are covered. Emergency services will be covered outside your service area
  • Maximum out-of-pocket Costs: There is a maximum limit on annual out-of-pocket costs. The maximum out-of-pocket costs range from $2,500 to $6,700 in 2021.
  • Out of Network Costs: You will pay 100% of out of network costs, except in emergency situations.
  • Primary Care Physician: You may need to select a primary care physician and you may need a referral for specialists.
  • Prior Approval: It is important that you follow the plan’s rule, like getting prior approval for certain services.  
  • Prescription Drug Plan (Part D): You must get a plan with drug coverage as a stand-alone plan cannot be added

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PPO – Preferred Provider Organization plans: PPO plans cover providers both in and out of network. These plans pay a portion of the cost for using an out-of-network provider. You pay more if you see providers outside of the network.  

  • Networks: Generally, you can receive care from any doctor that participates in Medicare, but you may pay lower costs if you go to one of the “preferred” doctors in the plan’s network. 
  • Emergency Services: You are covered. Emergency services will be covered outside your service area
  • Out of Network Costs: Typically, there are higher costs for seeking care outside of the “preferred” network
  • Maximum out-of-pocket Costs: There is a maximum limit on annual costs for both in-network and out-of-network costs. The general range is from $6,700 to $10,000 in 2021. However, don’t be surprised to find a PPO plan with costs as low as $3400.   
  • Primary Care Physician: You do not need to choose a primary care doctor.  
  • Referrals: You will likely NOT need a referral to see a specialist.
  • Prescription Drug Plan (Part D): You must get a plan with drug coverage as a stand-alone plan cannot be added

SNPs – Special Needs plans: Special Needs plans limit membership to people with specific diseases. Special Needs Plans have benefits that cover special health care or financial needs. All SNPs include prescription drug coverage.

  • Dual-Eligible Special Needs Plans (DSNPs) for people who have both Medicare and Medicaid (dual eligible plans).
  • Chronic Special Needs Plans (CSNPs) for people living with severe or disabling chronic conditions.
  • Institutional Special Needs Plans (ISNPs) for people who live in a skilled nursing facility.
  • Institutional-Equivalent Special Needs Plans (IESNPs) for people who live in a contracted assisted living facility and need the same kind of care as those who live in a skilled nursing facility.

Learn more about Special Needs Plans

PFFS – Private Fee-For-Service plans: PFFS plans may or may not have a provider network, but cover any provider who accepts Medicare. If the plan doesn’t include prescription drug coverage, you can also enroll in a standalone Part D plan separately.

  • Networks: Some PFFS plans contract with network providers and if the PFFS plan has a network, the enrollee may pay more for out-of-network providers. Non-network providers can choose to accept coverage on a patient-by-patient and visit-by-visit basis.
  • Emergency Services: Except for in emergencies, enrollees must inform providers before receiving care that they are enrolled in a PFFS plan so the non-network providers can decide if they will take the plan or not.
  • Providers: Most PFFS enrollees can receive care from any provider nationwide that participates in Medicare. However, the provider MUST agree to the terms and conditions of the payment according to the insurance company.

POS – Point of Service plans:  POS plans have the benefits of an HMO, but with more flexible provider choices.  Costs are usually lower for using in-network providers, but these plans will at least allow for out-of-network costs. 

Medical Savings Account Plans:  MSA plans are very unique.  These plans combine a high deductible insurance plan with a Medical Savings Account.  The plan will only cover you once you have met your high deductible.   Additionally, the plan deposits money into an account much like an HSA.  You can choose to spend the money to pay your health care costs before you meet your deductible.  Your deductible is usually very high.   Unlike other plan types, this plan does not have a network of doctors. 

The table below shows high-level differences between different Medicare Advantage plan types: 

HMO / HMO POSPPOPFFSSpecial Needs
Out-of-network coverage?Only in an emergencyCovered, plan allows for out-of-networkCovered, plan allows for out-of-networkSometimes
Primary care physician required?Yes, in most plansNoNoYes, in most plans
Referral necessary for specialist visit?YesNoNoSometimes
Prescription drug coverage?Yes, in many plansYes, in many plansSometimesYes
Emergency services covered?YesYesYesYes
Additional benefits?Yes, in most plansYes, in most plansYes, in most plansYes, in most plans

Learn More: When can I enroll in a Medicare Advantage Plan?

People Also Read: Medicare Advantage Plans: Example of Costs for Deductible, Copays, Coinsurance and more.

Meet Melissa MacCalla

Medicare is not simple and can be hard, frustrating, and downright confusing for most. I love when I get someone on the phone and I am given the opportunity to explain the difference in plans to them and have Medicare make sense. I enjoy talking to clients year after year, hearing about their families growing or them asking about mine.

-Melissa

Senior Healthcare Solutions, you truly stand out from most other insurance agents. Thank you so much for all of your help and I know that you will have nothing but success with how you conduct business.

Joan B.

Montgomery, AL

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