If you’re over 65, you’ve probably heard of Medicare Advantage. These plans, administered by private companies rather than the government (as Original Medicare is), feature options that make them attractive to many people. In fact, more than 23 million people, out of the 61 million who are eligible for Medicare choose Advantage plans over Original Medicare.
Why the popularity? Medicare Advantage plans differ depending on the company that is overseeing them, but in general they offer benefits beyond what Medicare Part A and B offer, such as vision, hearing, and dental coverage, gym memberships, and drug coverage. Plus, the all-in-one nature of the plans makes them easy to manage. Choosing a plan that’s right for your circumstances may also save you money in the end.
It can be confusing, though, to find the right plan for you. You’ll need to choose between an HMO, PPO, PFFS, or another type of plan. Let’s take a look at what this alphabet soup of acronyms means, and how each will impact your search for the best health care.
What Are the Different Types of Medicare Advantage Plans?
There are a handful of different types of Medicare Advantage plans, and how your care is delivered will depend on which plan you’re enrolled in. Each type has advantages and disadvantages, and it’s important to understand the restrictions in place for each one.
Medicare Advantage Health Maintenance Organization (HMO) Plans
These plans feature a network of approved health care providers in your region, and in order for your insurance to pay for a doctor’s visit or other health care need, you must use the providers that are in your network. The exceptions are for emergency care, out-of-area urgent care, and out-of-area dialysis. If you have a favorite doctor that you’d like to keep seeing, find out if they are in the network before you sign up for an HMO plan. You’ll need to get referrals for any specialist care from your Primary Care Physician (PCP) in an HMO — if you don’t, you may have to pay the full cost of service. Prescription medications are not automatically covered with HMOs; you’ll need to look at your plan’s benefits to see if drugs are covered.
Medicare Advantage Preferred Provider Organization (PPO) Plans
PPO plans also have a network of approved health care professionals and hospitals, and you’ll pay less if you use them. But you can go out-of-network when needed, though there may be a higher copay or coinsurance cost. You don’t need to choose a PCP, nor do you need a referral when you require specialist care in most cases. Prescription medications are not automatically covered with PPO plans, although some drugs may be covered.
Medicare Advantage Private Fee-for-Service (PFFS) Plans
PFFS plans may or may not have a network, but in general you can go to any Medicare-approved doctor or hospital. You won’t need to choose a PCP or get referrals. Some PFFS plans contract with a network of providers, and if so, they have agreed to treat you even if you’ve never been to them before, no matter what your health needs are. At the same time, out-of-network doctors, hospitals, and other providers aren’t required to treat you or accept the plan’s payment terms. Prescription medications are not automatically covered with PFFS plans; you’ll need to look at your plan’s benefits to see if drugs are covered.
Medicare Advantage Health Maintenance Organization Point of Service (HMO POS) Plans
An HMO POS plan is similar in many respects to the basic HMO plans, and also bears some similarities to PPO systems. You’ll choose your health care providers from within an approved network, but can go out-of-network in certain circumstances. You’ll choose a PCP to coordinate your care, and although you don’t generally need referrals, you may need to work with your PCP to get prior authorization for some services. Unlike HMO and PPO plans, however, HMO POS plans have two separate deductibles, one for in-network services and one for services outside of the network. These need to be reached separately before your insurance kicks in.
Medicare Advantage Special Needs Plans (SNPs)
SNPs, as the name suggests, are for people who have specific health care needs that are significant. These include diabetes, end-stage renal disease, HIV/AIDS, chronic heart failure, or dementia. Certain plans also treat people in care facilities or those who require nursing care at home. Unlike the other Medicare Advantage plans, SNPs provide Medicare prescription drug coverage, which is geared toward the medications commonly used by those with the illness. SNPs coordinate your health care needs, and require you to choose a PCP or have a care coordinator who helps with your health care.
How to Choose a Medicare Advantage Plan
So how do you find the plan that’s the best fit for your needs? A good place to start is the Medicare website. Here, you’ll find resources to help you compare Medicare Advantage plans and learn about your options with each one.
Before you even begin to look, it’s important to know that each plan is different — up to a point. What they have in common is their Medicare Part A and Part B coverage — all Advantage plans are required to include coverage for this care at a minimum. But over and above that, it’s up to each insurance company to create a benefits package for its customers, and those differ from company to company.
So, for example, if you wear a hearing aid and have frequent appointments with an audiologist, it would be in your best interests to search for a plan that includes hearing coverage. If you’re an avid exercise buff, a plan that features SilverSneakers gym memberships would be a nice option.
While you search for your Medicare Advantage plan, here are a few questions to keep in mind:
- Do you have a favorite doctor you’ve been seeing for years? If you choose a plan with a network of preferred providers, make sure your doctor is on the list. The same is true of hospitals — if you have several in your region, it’s good to know that the one you prefer will accept your Advantage insurance.
- Do you take medications on a maintenance schedule? If so, make sure that your plan includes drug coverage. Most Medicare Advantage plans do — but not all of them.
- What is your chosen plan’s deductible? The higher the deductible, the more you’ll pay out-of-pocket before your plan kicks in.
- Likewise, what are the copays? If you frequently need to see a healthcare professional for a chronic condition, a plan with lower copays makes sense, and may even make up for higher monthly premiums.
- Do you have frequent vision, dental, or hearing issues? A plan that covers these health care needs may save you money.
How Do I Find Medicare Advantage Plans Near Me?
Since most insurance companies offer only regional coverage, not all plans will be active in all areas of the country. To find out the plans that are available in your area, start with the Medicare “Find a Medicare Plan” page.
This page allows you to input your zip code and then choose to search for Medicare Advantage plans. You can customize your search to add information on the medications you take and your dosages, as well as whether you use generic or brand name drugs.
The resulting page will show you all the plans that are available to you, along with, for each plan:
- Your monthly premium
- Your yearly drug cost
- Your annual deductible for drugs, in-network, and out-of-network health care
- Plan benefits, such as vision, dental, and hearing
- Copays or coinsurance for your PCP and specialists
Once you choose a plan, you can start the enrollment process right from that page. Remember that there are only certain times you can sign up for Medicare Advantage, most notably in the three months before and after you turn 65, or 24 months after you first receive Social Security or Railroad Retirement Board disability benefits.
It may take a little time to compare all the plans and weigh your options, but it’s worth it to find a plan that will provide you with excellent and comprehensive health care at a cost that works for you.