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What is a Medicare Advantage Plan?
A type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all of your Part A and Part B benefits. Medicare Advantage Plans include:
• Health Maintenance Organizations
• Preferred Provider Organizations
• Private Fee-for-Service Plans
• Special Needs Plans
• Medicare Medical Savings Account Plans
If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and Medicare services aren’t paid for by Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
There are several types of Medicare Advantage plans available. Here are a few examples.
Health Maintenance Organization HMO
In most HMO Plans, you generally must get your care and services from providers in your plan's network, like, Doctors, Other health care providers, and Hospitals.
In HMO Plans, you generally must get your care and services from providers in the plan's network, except, emergency care, out-of-area urgent care, out-of-area dialysis.
In some plans, you may be able to go out-of-network for certain services. But, it usually costs less if you get your care from a network provider. This is called an HMO with a point-of-service (POS) option.
In most cases, prescription drugs are covered in HMO Plans. You would want to ask the plan you choose. If you want Medicare prescription drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage. In most cases, yes, you need to choose or designate a primary care doctor in HMO Plans. In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don't require a referral. If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan. If you get health care outside the plan's network , you may have to pay the full cost. It's important that you follow the plan's rules, like getting prior approval for a certain service when needed.
Preferred Provider Organization PPO
A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C)offered by a private insurance company. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. You pay more if you use doctors, hospitals, and providers outside of the network.
In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. PPO Plans have network doctors, other health care providers, and hospitals.
Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren't on the plan's list, but it will usually cost more.
In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn't offer prescription drug coverage, you can't join a Medicare Prescription Drug Plan (Part D).
You don't need to choose a primary care doctor in PPO Plans.
In most cases, you don't have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.
A PPO Plan isn't the same as Original Medicare or a Medicare Supplement Insurance (Medigap) policy.
PPO Plans usually offer extra benefits than Original Medicare, but you may have to pay extra for these benefits.
Special Needs Plans SNP’s
Medicare SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.
Generally, you must get your care and services from doctors or hospitals in the Medicare SNP network, except in Emergency or urgent care situations, like care you get for a sudden illness or injury that needs medical care right away. Or if you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis. Medicare SNPs typically have specialists in the diseases or conditions that affect their members.
All SNPs must provide Medicare prescription drug coverage. In most cases, SNPs may require you to have a primary care doctor. Or, the plan may require you to have a care coordinator to help with your health care. In most cases, you have to get a referral to see a specialist in SNPs. Certain services don't require a referral, like these, Yearly screening mammograms or An in-network pap test and pelvic exam (covered at least every other year).
An SNP plan must limit membership to these groups: 1) people who live in certain institutions (like a nursing home) or who require nursing care at home, or 2) people who are eligible for both Medicare and Medicaid, or 3) people who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia). Plans may further limit membership. You can join a SNP at any time. Plans should coordinate the services and providers you need to help you stay healthy and follow doctor’s or other health care provider’s orders. If you have Medicare and Medicaid , your plan should make sure that all of the plan doctors or other health care providers you use accept Medicaid. If you live in an institution, make sure that plan providers serve people where you live.