Medicare HMO plans are a type of coordinated care in which you will choose a primary care doctor in the network. You usually must get a referral from that doctor before you can see a network specialist.
Medicare PPO plans are also coordinated care, but many PPO plans allow you to see any doctor in the network at your own choosing, meaning a referral is not always required.
Medicare PFFS (Private-Fee-for-Service) plans generally have no network or a very small network. The company will allow any doctor to bill the plan as long as they agree to the plan’s terms and conditions up front. This puts the burden on you to ask your providers whether they will accept the plan before you seek medical services.
Medicare Advantage - What You Need To Know
- You are still part of Medicare: You must have Part A & B of Medicare to be eligible to enroll in an Advantage plan, and while on the plan you still have all of the rights and protections of Medicare.
- Networks for Doctors and Hospitals: Each company has its own network of doctors and hospitals. Be sure to check that your current doctors and hospitals are in network for the plan you are selecting.
- Pre-Existing Conditions: You can join a Medicare Advantage plan even if you have a pre-existing condition, with the exception of End- Stage Renal Disease (ESRD).
- Follow the Rules: In order to avoid extra costs you must be sure to follow the rules of your plan, such as staying in network, and getting a referral to see a specialist.
- Additional Benefits: In addition to standard Medicare benefits, many plans include coverage for Vision, Dental, Drugs, and even gym memberships.
- Low Monthly Premiums: Premiums for Medicare Advantage plans are typically fairly low since Medicare contracts with these insurance companies to provide your Part A & B benefits on behalf of Medicare.
All Medicare Advantage plans offer their own summary of benefits, and these benefits as well as the plan’s formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year.
Which Medicare Advantage programs are available to me?
Medicare Advantage programs have service areas. A licensed health insurance agent can help you determine which plan options exist in your county. He or she will help you work through a checklist of items to see which plan best suits you.