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Medicare Advantage Plan Basic Outline

A Medicare Advantage Plan, also known as Medicare Part C and MA plan, is one of the options you will have when deciding which Medicare health plan is best for you. These plans, like Medicare Supplements, are offered by private insurance companies. Even though these are offered by private insurance companies, there are still specific guidelines set by CMS they must follow. Some of Medicare Advantage Plans are also paired with Prescriptions Drug Plans (PDP) which is known as a MAPD.

Types of Medicare Advantage Plans

  1. Health Maintenance Organization (HMO) Plans
  2. Preferred Provider Organization (PPO) Plans
  3. Private Fee-for-Service (PFFS) Plans
  4. Special Needs Plans (SNP)

1. Health Maintenance Organization (HMO) Plans

With the Medicare HMO Plan, you generally use doctors and/or hospitals in your plans network with the exception of emergency care and out-of-state urgent care. In most cases, you will also need a primary care physician (PCP). Usually, your PCP is responsible for taking care of your primary needs and if need be, referring you to a specific specialist that also participates in your plan’s network.

2. Preferred Provider Organization (PPO) Plans

With a Medicare PPO Plan, you also have a network of doctors and hospitals. The difference in a PPO and an HMO is with a PPO you can usually use doctors or hospitals outside of your network but you will be responsible for some higher costs. Also, with PPO plans, there is no PCP and referrals usually are not needed to see a specialist.

3. Private Fee-for-Service (PFFS) Plans

With the Medicare PFFS Plan, there is usually not a network of doctors or hospitals to choose from. You are able to see any doctor or use any hospital that accepts Medicare, if they agree to the terms and conditions set by the plan. Like all Medicare Advantage Plans, emergency care or out-of-state urgent care is always covered by plan.

4. Special Needs Plans (SNP)

The Medicare SNP is limited to people who meet the criteria specified. This usually includes a certain group of people who are living in institutions (such as a nursing home), people who are dual-eligible (have Medicare and Medicaid), or people who have specific chronic or disabling conditions. These plans are usually responsible for coordinating the services and providers you need in order to stay healthy.

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