Did you know there are several different types of Medicare Advantage plans? You might have a choice of several kinds, such as:
- HMO (Health Maintenance Organization)
- PPO (Preferred Provider Organization)
- PFFS (Private fee-for-service)
- SNP (Special Needs Plan)
A Brief Summary of Medicare Advantage
Let’s start with a quick overview of the Medicare Advantage (Part C) program before comparing Medicare Advantage plans. Medicare Advantage gives you an alternative way to get your Original Medicare (Part A and Part B)) benefits. Under Medicare Advantage, you receive these benefits through a private insurance company that contracts with Medicare. You’re still in the Medicare program, but now a private company administers these benefits and delivers them to you. The exception is hospice care, which is still covered directly under Part A
Many Medicare Advantage plans go beyond Original Medicare coverage. For example, most plans include routine dental coverage, SilverSneakers fitness programs, and other benefits.
As you compare Medicare Advantage plans, please note that you still have to pay your monthly Part B premium, along with any premium the Medicare Advantage plan might charge.
Comparing the Types of Medicare Advantage Plans
Health Maintenance Organization (HMO) – You might be familiar with this type of plan if you were ever covered by an employer through an HMO. Medicare Advantage plans typically:
- Have provider networks
- Require you to go to providers within the plan’s provider network n order to be fully covered
- Require you to choose a primary care provider
- Require a referral if you want to see a specialist
HMOs often have lower premiums than other types of Medicare Advantage Plans.
Preferred Provider Organization (PPO) – Some employer group plans are PPOs, so you might know something about this type of plan. Medicare Advantage PPO plans typically:
- Have provider networks
- Let you go to providers outside the plans provider network, but might charge more for such visits.
- Don’t require you to choose a primary care provider.
- Don’t require a referral if you want to see a specialist.
Health Maintenance Organization Point-of-Service (HMO-POS) – This type of plan is similar to an HMO, but may let you get care outside the plan network. Medicare Advantage HMO-POS plans typically:
- Have provider networks
- Let you go to providers outside the plan’s provider network, but might charge a higher copayment or coinsurance for such visits.
Private Fee-for-Service (PFFS) – This type of plan sets its own payment structure. The plan decides how much it will pay its Medicare providers, and how much you will pay as a patient. Here are some things to know about PFFS plans:
- Some plans let you visit any health-care provider who accepts Medicare assignment and accepts the PFFS plan’s payment terms.
- Other plans may have provider networks whose doctors have agreed to always treat plan members. Generally, you can seek care outside the network, but you might pay higher costs, and you need to make sure the provider accepts the plan’s payment terms.
- PFFS plans don’t require you to choose a primary care provider
- PFFS plans don’t require referrals for specialist visits
- You pay only the plan’s coinsurance or copayment amount at the time of service.
Special Needs Plans (SNPs) – This is a special kind of Medicare Advantage plan designed to serve people with specific health conditions or meet certain other qualifications. SNP plans typically:
- Require you to use providers in the plan network, except in emergencies, or if you need kidney dialysis outside your plan’s service area.
- Have specialists in the specific condition that qualifies you for the SNP plan. For example, if you have chronic heart failure, your SNP would typically have cardiologists available.
- Provide prescription drug coverage
- Require you to select a primary care provider, or a care coordinator
- Require referrals to specialists
- Allow enrollment anytime you qualify, rather than during a specific enrollment period.
Who’s Eligible for a Medicare SNP?
First, you must be enrolled in both Medicare Part A and Part B (as with any type of Medicare Advantage plan). You must also live in the plan’s service area.
You might qualify for an SNP if any of the following applies to you.
- You qualify for Medicare and Medicaid.
- You live in a nursing home or similar institution
- You’ve been diagnosed with a severe or disabling health condition such as end-stage renal disease (kidney disease requiring dialysis), end-stage liver disease, dementia, chronic heart failure, cancer, diabetes mellitus. Please note that this isn’t a complete list of conditions that may qualify you for an SNP.
Medicare Medical Savings Accounts (MSAs) – This is a special kind of Medicare Advantage plan that charges a high deductible, but sets up a bank account for you to use for your health-care costs before you pay your deductible.