Medicare Advantage plans are designed to be “all in one” plans, covering hospitalization, doctor’s office visits, prescriptions, labs and diagnostic tests, plus other unique benefits that vary between plans and carriers, like eye exams and glasses, gym memberships, and transportation to and from medical appointments.
What Types of Medicare Advantage Plans are there?
Health Maintenance Organization – HMO
In HMO plans, you are expected to go to doctors and hospitals in your plan’s network, except in an emergency. Some HMOs may allow you to see out-of-network doctors or use out-of-network hospitals for a higher cost, but some may not cover out-of-network services at all. In HMOs, you will pick a specific primary care physician, and you generally will need a referral from that doctor to see a specialist or receive certain kinds of other services.
Preferred Provider Organization – PPO
In PPO plans you’re not required to see only doctors that are part of your plan’s network, but your cost will be less if you see one of these “preferred” doctors. In most cases, you can see a specialist without needing a referral, though this can vary depending on the carrier and the plan.
Private Fee-For-Service – PFFS
In PFFS plans, your insurance carrier has established what it will pay for what services and other payment terms, and it’s up to individual doctors to decide whether they will accept those terms. Doctors can choose whether or not to accept your PFFS plan’s terms at each visit, and doctors even within the same practice may not at all accept your plan.
Medicare Medical Savings Account – MSA
MSA plans combine a high-deductible health plan with a special type of savings account called a Medical Savings Account. The health plan will only begin to cover your medical expenses once a high yearly deductible is met, and your plan deposits money into your Medical Savings Account that you can use to pay your health care costs before you meet your deductible.
Are there Limitations in What Coverage I’ll be able to get?
If you have been diagnosed with one of a specific group of chronic conditions, including diabetes and cardiovascular disorders, you are eligible for coverage through a type of Medicare Advantage plan called a Chronic Condition Special Needs Plan (C-SNP). You can find more information on what conditions can make you eligible for one of these plans on Medicare.gov by clicking here. These plans are limited to people with one or more of those conditions, and are designed to offer coverage specifically tailored to help treat and manage those conditions. SNPs are offered by private insurance carriers, the same as other Medicare Advantage plans, and vary depending on where you live. You can find out which plans may be available in your area by visiting Medicare.gov. One of our agents is also happy to help you if you contact our office at 877-776-8919.
If you have a chronic condition covered by a C-SNP, you are not obligated to choose a SNP even if one is available to you, and insurance carriers cannot deny you coverage because of it.
There are also other types of Special Needs Plans available. People who are eligible for both Medicare and Medicaid can enroll in a Dual Eligible Special Needs Plans (D-SNP). People who live in a nursing home or other long term care facility or require a similar level of care at home are eligible to enroll in an Institutional Special Needs Plan (I-SNP).
Can I Keep my Doctor?
In many cases, yes. If you choose coverage through a Medicare Advantage plan, you may be expected to see doctors from a specific network and your doctor may or may not be included in that network. You can check with your doctor to see which Medicare Advantage plans he or she works with, and you can check Medicare.gov to see which plans are available in your area. Sometimes nearby areas that are served by the same doctors or medical groups may not be served by the same Medicare Advantage plan carriers, so be sure to check which carriers you would be eligible to enroll with, or call us to have one of our agents help!
Will I Have to Pay a Premium?
You may or may not have to pay a premium, and the total cost of that premium will vary depending on the type of plan you choose and whether your income or other factors qualify you for premium assistance. You will need to continue to pay your Part B premium in addition to whatever premium your Medicare Advantage plan charges. You can find more information on premium assistance programs on Medicare.gov by clicking here.
What’s the Difference Between a Copay and Coinsurance?
Most types of medical insurance typically require members to pay some portion of the costs of services they receive, in the form of copays and coinsurance. Copays, or copayments, are set costs for different kinds of services. For example, a Medicare Advantage plan may have $10 copays for all primary care doctor’s visits. With coinsurance, members are charged a percentage of the cost of the services they receive, rather than a flat amount. For example, some plans may charge a 20% coinsurance for office visits, so that if your doctor charges $100 for an office visit, your insurance will pay $80 and you will be responsible for the remaining $20.