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MEDICARE ADVANTAGE PLANS

(PART C)

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HEALTH MAINTENANCE ORGANIZATION (HMO)

HMO Plans—also called Medicare Advantage Plans (Part C)—use a network of primary care providers to coordinate care. As with all HMO plans, you must receive your care and services from providers in the plan's network, except:

  • Emergency care

  • Out-of-area urgent care

  • Out-of-area dialysis
     

Some plans allow you to go out-of-network for certain services. However, your costs are usually lower if you receive care from a network provider, known as an HMO with a point-of-service (POS) option. 

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Most Medicare HMO plans have extra benefits not available from Medicare Parts A and B, such as:

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  • Routine dental care and some comprehensive coverage

  • Eye exams, eyeglasses, and corrective lenses

  • Hearing tests and hearing aids

  • Wellness programs and fitness memberships

  • Over-the-counter drugs and supplies

  • Transportation

  • Worldwide coverage on some plans

  • Maximum out-of-pocket protection  

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Premium costs vary; most are at zero premium, depending on where you live.
There are no additional costs for the plan.

PREFERRED PROVIDER ORGANIZATION (PPO)

PPO Plans offer network doctors, other health care providers, and hospitals. Your costs are less if you choose doctors, hospitals, and other health care providers that belong to your plan's network. Conversely, your costs are higher if you use doctors, hospitals, and providers outside of the network. If a PPO does not have a prescription drug plan, you are not eligible to buy a stand-alone drug plan.

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Advantages

  • You do not have to select a primary care physician (PCP).

  • You can choose any doctor (but you'll pay less out-of-pocket costs for
    in-network providers).

  • No referral is required to see a specialist.

  • The PPO offers more flexibility than other plan options.

  • You have greater control over your choices.​

  • Your plan may come with extra benefits like vision, dental, hearing, and over-the-counter medications.  

  • Some PPO plans have zero-cost premiums, depending on the carrier.

Choose your own doctor with a PPO plan.

HEALTH MAINTENANCE ORGANIZATION

SPECIAL NEEDS PLAN (HMO-SNP)

Similar to HMOs or PPOs, Medicare SNPs are Medicare Advantage Plans. However, Medicare SNPs limit membership to people with specific diseases or characteristics broken down into three categories: Chronic Condition SNP, Institutional SNP, and Dual Eligible SNP.  

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  • These plan administrators design the benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.​ 

  • You are required to get your care and services from doctors or hospitals in the Medicare SNP network, except:​ 
    • Emergency /urgent care for a sudden illness or an injury     ​
    • End-Stage Renal Disease (ESRD) patients who need out-of-area       dialysis

Meeting your urgent care needs

PRIVATE FEE-FOR-SERVICE (PFFS)

A Medicare PFFS Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PFFS plans aren’t the same as Original Medicare or Medigap. These plans determine how much they will pay doctors, other health care providers, and hospitals and how much the policyholder must pay for care. 

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Some plans have prescription drug coverage. However, if your plan doesn't offer it, you can purchase a stand-alone drug plan.

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If you join a PFFS Plan that has a network, you can also see any of the network providers who have agreed to always treat plan members. You can also choose an out-of-network doctor, hospital, or another provider who accepts the plan's terms. Your costs, however, will usually be lower if you stay in the network.

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We can help you determine which PFFS Plan is available to you and what that plan will offer.

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