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Medicare Advantage Plan Options


The most common types of Medicare Advantage Plans include organizations such as Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS), and Special Needs Plans (SNPs).


Health Maintenance Organization Plans (HMO)


With a Medicare HMO Plan, the insured generally must choose healthcare providers and hospitals in the plan’s network, with exception of emergency care, out-of-area urgent care, and temporary out-of-area dialysis. Medicare HMO Plans offer low premiums and in some situations, the premiums could be as low as $0, although you will still need to pay the premium for Medicare Part B. Most plans include Medicare drug coverage (Part D).


Although your healthcare provider will be determined based on the in-network physicians available, you would have the option to use an out-of-network doctor if your primary care physician is unable to provide care although at a higher cost. In some scenarios, you would be required to receive a referral card by your primary care physician with exception to services like emergency visits, mammograms, and preventative care. 


HMO quick-look:


  • Must use doctors, other health care providers, and hospitals in-network with the exception of emergency care, out-of-area urgent care, and temporary out-of-area dialysis
  • Most plans include Medicare drug coverage (Part D)
  • Must choose a primary care doctor
  • Must get a referral to see specialists, with some exceptions
  • If you choose to get healthcare outside of your plan’s network, you may have to pay higher costs


Preferred Provider Organizations (PPO)


PPO Plans provide both Plan A and Plan B benefits under your plan and put a cap on the out-of-pocket expenses to protect the insured from high medical bills. PPO Plans offer similar benefits to HMOs, but you are able to see doctors out of network, usually at a higher cost, as long as they accept Medicare. You are always covered in and out of network for emergency care services.  PPO insured have the ability to see specialists without the need for referrals. Due to this flexibility, the premiums and deductibles may be more than an HMO Plan. If you want drug coverage, you must choose a plan with Medicare drug coverage (Part D).


The main benefit of a PPO Plan for an insured is the freedom to see out-of-network medical professionals, but the cost for those visits will be higher than your traditional in-network providers. Part D is typically included in this coverage as well so you’ll have your prescription drugs expenses taken care of. For some plans, you could have access to other services such as vision and hearing. 


Health Maintenance Organization Point-of Service (HMO-POS)


HMO-POS plans provide coverage for both in-network services and some out-of-network services. Your hospital and medical services are only covered through in-network services, however, there are some services that you’ll receive out-of-network coverage but at a higher cost. Like a HMO plan, your care is coordinated through your primary care physician and even though it’s not required to get a referral to see a specialist, this can help with getting an appointment sooner. You do, however, need to work with your doctor to get prior authorization before you get some services or your plan may not provide coverage.


Differences between HMO and PPO Plans



Private Fee-For-Service (PFFS)


PFFS Plans offer the most flexibility of the Medicare Advantage plans as you’re not presented or limited to a specific network of providers. The insured will have the ability to see any Medicare-participating provider in the country as long as the provider agrees to accept the plan’s payment terms and conditions. This plan is quite common with Medicare recipients who travel often as they would need that flexibility of care. 


It’s important to understand that PFFS is not a Medicare Supplement insurance and providers who do not contract to the plan are not required to provide services with an exception to emergency care. Because of this, the insured has the responsibility to discuss this coverage with their healthcare provider prior to treatment to ensure coverage exists.


Special Needs Plans (SNPs)


SNPs are a type of Medicare Advantage Plan that provides care and membership to people with specific diseases and characteristics. One can join this plan if they meet these requirements:

  • You have Medicare Part A and Medicare Part B 
  • You live in the plan’s service area
  • You meet the plan’s eligibility standards for one of the 3 SNP types
    • Chronic Condition SNP 
      • Examples include chronic alcohol dependency, certain autoimmune diseases, cancer, certain cardiovascular disorders, chronic heart failure, dementia, diabetes mellitus, end-stage liver disease, end-stage renal disease, certain severe hematologic disorders, HIV/AIDs, certain chronic lung disorders, certain chronic and disabling mental health conditions, certain neurologic disorders, and stroke.
    • Institutional SNP
      • You live in the community but need the level of care a facility offers, or if you live for at least 90 days straight in a facility like:
        • Nursing home, intermediate care facility, skilled nursing facility, rehabilitation facility, long-term care hospital, swing-bed hospital, psychiatric hospital, and other similar long-term health care facilities 
    • Dual Eligible SNP
      • You’re eligible for both Medicare and Medicaid through SNPs.


What Plan is the Right One?


Medicare insurance can be complex but it doesn’t need to be! The skilled and personable independent agents here at Tepsick Insurance understand how to perfectly craft a plan that’s right for you. Connect with one of our agents today for a free consultation and discover how to live with peace of mind.