Descriptions of the Different Medicare Advantage Plans

Descriptions of the Different Medicare Advantage Plans

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Health Maintenance Organization (HMO) Plan Preferred Provider Organization (PPO) Plan Private Fee-for-Service
(PFFS) Plan
Can I get my health care from any doctor or hospital? No. You generally must get your care and services from doctors and hospitals in the plan’s network (except emergency care, out-of-area covered services, usually for a urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services usually for a higher cost. Yes. PPOs have network doctors and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost In some cases, yes. You can go to any Medicare-approved doctor or hospital that accepts the plan’s payment terms and agrees to treat you. Not all providers will. If you join a PFFS Plan that has a network, you will usually pay more to see out-of-network providers.
Are prescription drugs covered? In most cases, yes. Ask the plan. If you want drug coverage, you must join an HMO Plan that offers prescription drug coverage. In most cases, yes. Ask the plan. If you want drug coverage, you must join an PPOPlan that offers prescription drug coverage. Sometimes. If your PFFS Plan doesn’t offer drug coverage, you can join a Medicare Prescription Drug Plan to get coverage.
Do I need to choose a primary care doctor? In most cases, yes. No. No.
Do I have to get a referral to see a specialist? In most cases, yes. Yearly screening mammograms and in-network Pap tests and pelvic exams (at least every other year) don’t require a referral. No. No.
What else do I need to know about this type of plan?
  • If your doctor 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 the getting prior approval for a certain service when needed.
  • There are two types of PPOS – Regional PPOs and Local PPOS.
  • Regional PPOs serve one of 26 regions set by Medicare.
  • Local PPOs serve the counties PPO Plan chooses to include in its service area.
  • PFFS Plans aren’t the same as Original Medicare or MediGap.
  • The plan decides how much you must pay for services.
  • Doctors, hospitals, and other providers may decide on a case-by-case basis not to treat you even if you’ve seen them before.
  • For each service you get, check to make sure your doctors, hospitals, and other providers will agree to treat you under the plan, and they will accept the PFFs Plan’s payment terms.
  • In an emergency, doctors, hospitals, and other providers must agree to treat you.
  Special Needs Plan (SNP)
Can I get my health care from any doctor or hospital? You generally must get your care and services from doctors or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). Plans typically have specialists for the diseases or conditions that affect their members.
Are prescription drugs covered? Yes. All SNPs must provide Medicare prescription drug coverage (Part D).
Do I need to choose a primary care doctor? Generally, yes, or you may need to have a care coordinator to help plan your care.
Do I have to get a referral to see a specialist? In most cases, yes. Yearly screening mammograms and an in-network Pap test and pelvic exam (at least every other year) don’t require a referral.
What else do I need to know about this type of plan?
  • A plan must limit plan membership to people in one of the following 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 one or more specific chronic or disabling conditions (like diabetes, congestive heart failure, a mental health condition, or HIV/AIDS).
  • Plans may further limit membership within these groups.
    Plans should coordinate the services and providers you need to help you stay healthy and follow your doctor’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 doctors or other health care providers serve people where you live.

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