Medicare Advantage Plan Types

Medicare Advantage Plan Types

Medicare Advantage plan types can be difficult to understand since select plans are available in certain areas. Original Medicare health insurance coverage is split into four main parts. Each part covers specific aspects of your health care needs.

Part A covers hospital care and inpatient services. Then, Part B is your medical insurance for regular doctors’ visits, medical procedures, and equipment. Part D can be thought of as a prescription drug card.

Wait, what about Part C? Medicare Part C is formally known as the Medicare Advantage Supplement Plan. Part C plans provide coverage options to replace Medicare.

Coverage includes co-payments, deductibles, and other medical costs that could drain your savings. For instance, if you suddenly become seriously ill.


Medicare Advantage Plan Types

Medicare Advantage and Medigap are the 2 ways to protect your wallet against excess costs in case of illness. These plans help give you additional coverage for gaps in Medicare.

To add more acronyms to the list, these supplement plans are broken down into different plan types. Plan types include HMO, PPO, SNP, PFFS, and MSA. These plans and plan types come with a ton of information.

Understanding Medicare Advantage Plan Types makes enrollment easier.


“All-In-One” Medicare Advantage Plans

Medicare Advantage (MA) Plans are also private insurance plans that help with gaps in Medicare coverage. Although they sound like Medigap plans, don’t confuse the two as they have some notable differences.

To be eligible for MA enrollment you must enroll in Medicare Parts A and B and be current on Part B premium payments.

Beneficiaries with End-Stage Renal Disease (ESRD), won’t qualify for Advantage plans

About 30% of Medicare beneficiaries choose Medicare Advantage plans over Medigap plans due to the cost of premiums being much lower. The only premium cost you must pay for MA is your monthly Part B premium.

Your Medicare Advantage plan will pay for the cost of healthcare bills, rather than Original Medicare. Beneficiaries pay costs for services from providers in the plan’s network. Although the value of copayments is reasonable, you’ll want to still look over them prior to enrollment.

Many Advantage plans come with a Part D coverage plan, so enrolling in a separate drug plan isn’t necessary. For some, the convenience of this is great!

On the contrary, some beneficiaries have seen financial devastation. Check your Advantage plan’s drug formulary to ensure your prescriptions is enough. Otherwise, the cost of meds can be quite expensive.


The Many Types of  Medicare Advantage Plans

When choosing a Medicare Advantage Part C plan, you’ll need to consider the different plan types to ensure proper coverage. We’ve broken down each plan type to help you better understand coverage options.


Health Maintenance Organization (HMO)

For beneficiaries with HMO plans to receive coverage for care; you must receive services from health care providers in your plan’s network.

Some plans, however, will allow you to get care from an out-of-network provider; although, the cost will be higher. This is formally known as a Medicare Advantage HMO with a point-of-service (POS) option.

For most, a referral requirement for a specialist is in place.

Should your doctor or health care provider leave, your plan notifies you. Following notification, you’ll be able to choose another doctor within the plan.


Preferred Provider Organization (PPO)

With PPO plans, you’ll pay less when visiting doctors, hospitals or any type of health care provider when they belong to the plan’s network.

Each PPO gives freedom to go to hospitals and/or see specialists/doctors that aren’t on your plan’s list. Be mindful though, as these services come with additional costs.

PPO plans give you the freedom to see any type of doctor. Opposite of HMO, it’s not necessary to choose a primary care physician with PPO and referrals aren’t a must to see a specialist.


Private-Fee-For-Service (PFFS)

Medicare PFFS plans are different from other types of Medicare Advantage plan. Beneficiaries can seek health care from any Medicare physician, provider, or hospital that agrees to the plan’s payment terms and grants treatment of services.

Nevertheless, not all providers will accept the PFFS plan’s payment terms.

Of course, the cost will be higher; but you have options for an out-of-network health care provider and hospitals if they agree with the plan’s terms. PFFS plans may cover costs of prescription drugs; if not, you may enroll in a Medicare Part D Plan.

PFFS Plans don’t require choosing a primary care doctor; certain Medicare PFFS Plans have arrangements with a specific network of providers.

In contrast, out-of-network providers and hospitals can choose not to treat you in non-emergency situations. For emergencies, hospitals and other health care providers/doctors may not refuse you treatment.


Special Needs Plans (SNP)

Special Needs Plans restricts enrollment to individuals with specific diseases or disabilities. These plans adjust provider choices, benefits, and drug formularies to best meet the medical needs of the group they serve.

SNPs have specialists in the diseases or conditions that their members suffer from. You should get your services and care from health care providers and hospitals in your Medicare SNP network.

Emergency care for a sudden illness or injury is the exception, as immediate treatment is a must.


SNPs requirements:

  • The plan must include Medicare prescription drug coverage
  • Members must have a primary care physician or a care coordinator to assist with health care needs
  • Members will need a referral from their doctor before seeing a specialist
  • Yearly mammogram screenings, in-network Pap test, and pelvic exams have coverage at least every other year


Beneficiaries with specific disabling or severe conditions may join a Special Needs Plan at any time, once they qualify. Enrolling in an SNP in your service area can be done during the Special Enrollment Period.

Plans should set up the services and providers you need to keep you healthy. You must follow your health care provider’s instructions to ensure optimal results in the treatment of your condition.

For Medicare and Medicaid beneficiaries – your plan should ensure that all the plan health care providers you need to use will accept Medicaid.

Medicare Advantage Part C SNP Beneficiaries residing in an institution – make sure your plan’s providers treat people where you live, to avoid coverage issues.


Medical Savings Account (MSA)

MSA plans are similar in operation as Health Savings Accounts (HSAs); HSAs come from employers. The Medicare Medical Savings Account program gives a pre-set dollar amount to the plan, for costs of care.

Afterward, the plan deposits a portion of said dollar amount into health savings account for the beneficiary.

Beneficiaries may use these funds to cover the costs of medical care. Once the funds are gone, the beneficiary will be responsible for medical costs. This will continue until the plan’s deductible is met but remember, deductibles will probably be high.


Get Help With Medicare Advantage Plan Types!

Understanding Medicare Advantage Part C and all the supplemental plans that go with it can be a lot of information. Medicare Medigap is here to help you; speak with one of our agents, they commit to answering your questions.

If you need help further understanding the plan you’re researching, we can assist in finding the best plan options for your healthcare needs.

Call us today so we can help you decide what will best fit your health care needs and budget. If you can’t call now, you can fill out an online rate form and discover the policy with the most value.