When it comes to insurance coverage, there are many options available for those 65 and older. Medicare Advantage Plans are an alternative way to receive your Medicare Part A and Part B coverage. Advantage Plans are often referred to as “Part C” or “MA Plans” and made available by Medicare-approved private insurance carriers. Medicare Advantage is a way to replace Original Medicare benefits, while Medigap policy supplements Original Medicare coverage. Most of these plans cover prescription drugs, but you must visit in-network providers within the designated service area to keep costs low. The plans do include an out-of-pocket limit to help cover any unexpected charges. While such plans provide the same type of coverage under Medicare Part A and Medicare Part B, there still may be gaps in such coverage.
Below are the most common types of Medicare Advantage Plans:
- Health Maintenance Organization Plans (HMO)
- Preferred Provider Organization Plans (PPO)
- Private Fee-for-Service Plans (PFFS)
- Special Needs Plans (SNPs)
In general, you must get care from in-network providers except in the case of:
- Emergency care
- Out-of-area urgent care
- Out-of-area dialysis
You must choose your in-network primary care doctor. The plan should notify you if your doctor decides to leave the network. If you visit an out-of-network provider, you are typically responsible for the full cost of the visit. Referrals are usually required for any specialist visits unless the service required is part of routine yearly screening.
Private insurance companies offer PPOs with their own in-network doctors, hospitals, and other healthcare providers. Visiting in-network providers reduces your costs as you may have to pay more for practitioners outside of the network. This type of Advantage Plan does not require you to choose a primary care doctor, and you do not need a referral for specialist visits. PPOs usually offer more benefits than Original Medicare, but you will have to pay extra for those benefits.
In Private Fee-for-Service plans, the private insurance carrier (rather than Medicare) decides how much it will pay doctors, hospitals, and other care providers, in addition to how much you will have to pay out-of-pocket for each visit. You can visit any Medicare-approved practitioner who accepts the payment terms of the plan. It is crucial to make sure that the healthcare provider agrees with the PFF terms before any treatment, or you may be responsible for the cost. However, not all providers will accept, so it is best to visit those physicians and facilities if the plan offers a network. Depending on the type of plan, you may have prescription drug coverage, but if it is not available, you will need to sign up for Medicare Part D to fill prescriptions. PFFs do not require that you choose a primary care provider or get a referral for specialist services.
Special Needs Plans limit their membership to those with specific diseases or characteristics. The private insurance carriers base their benefits, provider choices, and drug formularies on the particular type of group they are servicing. Since care is specialized SNPs, usually have in-network providers who are experts in the disease or conditions of the members they serve. Generally, it would be best if you visited in-network providers to keep costs at a minimum. Only in emergency or urgent care and out-of-service dialysis cases do the plans provide coverage outside of the work. Unlike other plans, SNPs require you to have a primary care provider or care coordinator. Additionally, referrals are necessary for any specialist visits. Other important factors to note are that a plan must limit membership to people living in certain institutions, eligible for Medicaid and Medicare, and people with disabling or chronic conditions.
These are just four of the most common types of Medicare Advantage Plans. As you can see, there still may be gaps in coverage with these plans. To learn more detailed information on the different plans and how you can supplement your coverage, book an appointment with the experts at The Benefit Link. With over 28 years of experience and access to virtually every major insurance carrier, we can find the right plan for you!