What Types of Medicare Advantage Plans are there?

 

Health Maintenance Organization -- HMO

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In HMO plans, you are expected to go to doctors and hospitals in your plan’s network, except in an emergency.  Some HMO’s may allow you to see out-of-network doctors or use out-of-network hospitals for a higher cost, but some may not cover out-of-network services at all. In HMO’s, you will pick a specific primary care physician, and you generally will need a referral from that doctor to see a specialist of receive certain kinds of other services. Most HMO plans include prescription drug coverage.

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Preferred Provider Organization -- PPO

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In PPO plans you’re not required to see only doctors that are part of your plans network, but your cost will be less if you see one of these “preferred” doctors. In most cases, you can see a specialist without needing a referral, though this can vary depending on the carrier and the plan.  Most PPO plans include prescription drug coverage.

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Private Fee-For-Service -- PFFS

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In PFFS plans, your insurance carrier has established what it will pay for, what services and other payment terms, and it’s up to individual doctors to decide whether they will accept those terms. Doctors can choose whether to accept your PFFS plan’s terms at each visit, and doctors even within the same practice may not at all accept your plan.  Most PFFS plans include prescription drug coverage.

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Are there limitations in what coverage I'll be able to get?

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If you have been diagnosed with one of the specific groups of chronic conditions, including diabetes and cardiovascular disorders, you are eligible for coverage through a type of Medicare Advantage plan called a Chronic Condition Special Needs Plan (C-SNP).  You can find more information on what conditions can make you eligible for one of these plans on Medicare.gov.  These plans are limited to people with one or more of those conditions and are designed to offer coverage specifically tailored to help treat and manage those conditions.  SNPs are offered by private insurance carriers, the same as other Medicare Advantage plans, and vary depending on where you live.  You can find out which plans may be available in your area by visiting Medicare.gov.  Our agents can also assist you by contacting our office at (530) 345-5135.

 

If you have a chronic condition covered by a C-SNP, you are not obligated to choose a SNP even if one is available to you, and insurance carries cannot deny you coverage because of it.

 

There are also other types of Special Needs Plans available. People who are eligible for both Medicare and Medicaid can enroll in a dual Eligible Special Needs Plan (D-SNP). People who live in a nursing home or other long-term care facility or require a similar level of care at home are eligible to enroll in an Institutional Special Needs Plan (I-SNP).

 

Can I keep my doctor?

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In many cases, yes.  If you choose coverage through a Medicare Advantage plan, you may be expected to see doctors from a specific network and your doctor may or may not be included in that network.  You can check with your doctor to see which Medicare Advantage plans he or she works with, and you can check Medicare.gov to see which plans are available in your area.  Sometimes nearby areas that are served by the same doctors or medical groups may not be served by the same Medicare Advantage plan carriers, so be sure to check which carriers you would be eligible to enroll with or call us to have one of our agents help.

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Will I have to pay a premium?

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Most types of medical insurance typically require members to pay some portion of the costs of services they receive, in the form of copays and coinsurance.  Copays, or copayments, are set costs for different kinds of services.  For example, a Medicare Advantage plan may have $10 copays for all primary care doctors’ visits. With coinsurance, members are charged a percentage of the cost of the services they receive, rather than a flat amount.  For example, some plans may charge a 20% coinsurance for office visits, so that if your doctor charges $100 for an office visit, your insurance will pay $80 and you will be responsible for the remaining $20.

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