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Is Your Medicare Advantage Plan a Good Match for You?

Just like many private insurances, Medicare Advantage has different types of plans.

  • Health Maintenance Organization (HMO) Plans
  • HMO Point of Service (HMO-POS) Plans
  • Preferred Provider Organization (PPO) Plans
  • Private Fee-for-Service (PFFS) Plans
  • Special Needs Plans (SNPs)
  • Medical Savings Account (MSA) Plans

Which plan might be a good match for you? Let’s find out. First, ask yourself these questions:

Must I choose my health care provider from a network?

Most Medicare Advantage plan types do require you to choose your doctor, other health care providers, and hospitals from a network if you want full coverage. Some plans allow you to go out of network at a higher cost. And the provider must agree to treat you and hasn’t opted out of Medicare. You should always be covered for emergency care or urgent care out of network.

One exception: A Medicare Medical Savings Account or MSA plan. Most MSA plans don’t limit you to a network of doctors, other health care providers, or hospitals for coverage. This unique plan combines a high-deductible insurance plan with a medical savings account to pay for health care costs. If you want Medicare drug coverage, you’ll have to join a separate Medicare drug plan. MSA plans don’t charge a premium, but you must continue to pay your Part B premium. The plan will only begin to cover your costs once you meet a high yearly deductible, which varies by plan.

Do I have a preferred primary care doctor?

For some plans, such as HMOs and certain SNPs, you must choose a primary care doctor. This doctor will give you a referral if you need to see a specialist. Some HMO and SNP plans may not require referrals for some services, like an annual mammogram, but make sure to read the rules.

Other plan types, such as PPOs, PFFS plans, MSAs, and some SNPs, don’t require you to choose a primary care doctor. You also don’t need a referral to see a specialist.

Do I want prescription drug coverage?

This question is more important than it seems. Prescription drug coverage is included in most Medicare Advantage plans but not all. If you happen to choose a plan without drug coverage, most plan types don’t allow you to add a separate Medicare Part D drug plan.

PFFS and MSA plans are the only Medicare Advantage plan types where you can add separate Part D coverage.

Plans at a Glance

Medicare Advantage plan type Best for you if… Must my health care providers be in-network for coverage? Must I choose a primary care provider? Do I need a referral to see a specialist? Is drug coverage included?
HMO You want lower costs. Yes. If you get non-emergency health care outside the plan’s network without authorization, you may have to pay the full cost. Yes, in most cases. You’re covered out of network for emergency care, urgent care and temporary out-of-area dialysis. Yes, in most cases. Exceptions include some services like annual mammograms. Yes, in most cases. If not, Part D cannot be added.
HMO-POS You want an HMO plan. Some out-of-network services may be allowed for a higher copayment or coinsurance. Yes, in most cases. You may also need prior authorization to get full coverage. Yes, in most cases. If not, Part D cannot be added.
PPO You want flexibility and choice. You pay less if you go in-network. But you can use out-of-network providers for covered services for a higher cost. A provider must agree to treat you and hasn’t opted out of Medicare. No. But you can save money by using in-network (preferred) providers. You’re always covered for emergency and urgent care. No, in most cases. Yes, in most cases. If not, Part D cannot be added.
PFFS You have few medical needs. Costs are limited to your premium and coinsurance or copay for each service. Whether in or out of network, you must first make sure providers are eligible to receive payment from Medicare and agree to accept the plan’s terms and conditions of payment for each service you get. No No Sometimes. If it isn’t, you can add Part D.
SNP You need a plan that provides benefits and services to people with specific chronic diseases (C-SNP), certain health care needs in a facility (I-SNP), or who also have Medicaid coverage (D-SNP). Depends on the plan. SNPs tailor their benefits, provider choices, and list of drugs (formularies) to best meet the specific needs of the groups they serve. Depends on the plan. Depends on the plan. Yes
MSA You like being in control of your finances. These plans deposit money into an account annually to help cover your expenses. But they have high deductibles. Money left in your account at the end of year stays there. Not usually No No Not usually. You can add Part D.

Is it a match?

There are a lot of choices out there. Need to talk it out? Call our licensed insurance agents. They’ll help you navigate the different plan types. Together you’ll find a match for your health needs, lifestyle, and finances.

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MR702 1/2023