Medicare Advantage Plans

A Medicare Advantage Plan (like an HMO or PPO) is another way to get your Medicare coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies that Medicare approves. If you join a Medicare Advantage Plan, you’ll still have Medicare but you’ll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage Plan, not Original Medicare. You’ll generally get your services from a plan’s network of providers. Remember, in most cases, you must use the card from your Medicare Advantage Plan to get your Medicare-covered services. Keep your Medicare card in a safe place because you’ll need it if you ever switch back to Original Medicare.

What are the different types of Medicare Advantage Plans?

(All page numbers reference the official US government Medicare handbook)

  • Health Maintenance Organization (HMO) plans—In most HMOs, you can only go to doctors, other health care providers, or hospitals in the plan’s network except in an urgent or emergency situation. You may also need to get a referral from your primary care doctor for tests or to see other doctors or specialists. See page 90.
  • Preferred Provider Organization (PPO) plans—In a PPO, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You usually pay more if you use doctors, hospitals, and providers outside of the network. See page 91.
  • Private Fee-for-Service (PFFS) plans—PFFS plans are similar to Original Medicare in that you can generally go to any doctor, other health care provider, or hospital as long as they accept the plan’s payment terms. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care. See page 92. Important! Section 5—Learn about Medicare Advantage Plans (Part C) & Other Medicare 85 Health Plans Definitions of blue words are on pages 153–156.
  • Special Needs Plans (SNPs)—SNPs provide focused and specialized health care for specific groups of people, like those who have both Medicare and Medicaid, live in a nursing home, or have certain chronic medical conditions. See page 93.
  • HMO Point-of-Service (HMOPOS) plans—These are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance.
  • Medical Savings Account (MSA) plans—These plans combine a high-deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year. MSA plans don’t offer Medicare drug coverage. If you want drug coverage, you have to join a Medicare Prescription Drug Plan. For more information about MSAs, visit Medicare.gov/publications to view the booklet “Your Guide to Medicare Medical Savings Account Plans.”  Make sure you understand how a plan works before you join. See pages 90–93 for more information about Medicare Advantage Plan types. If you want more information about a Medicare Advantage Plan, you can call any plan and request a “Summary of Benefits” (SB) document. Contact your State Health Insurance Assistance Program (SHIP) for help comparing plans. See page 149 for the phone number.

Important Notes Regarding Medicare Advantage Plans

(All page numbers reference the official US government Medicare handbook)

  • You can check with the plan before you get a service to find out if it’s covered and what your costs may be.
  • You must follow plan rules. It’s important to check with the plan for information about your rights and responsibilities.
  • If you go to a doctor, other health care provider, facility, or supplier that doesn’t belong to the plan’s network, your services may not be covered, or your costs could be higher. In most cases, this applies to Medicare Advantage HMOs and PPOs. Important! 86 Section 5—Learn about Medicare Advantage Plans (Part C) & Other Medicare Health Plans Definitions of blue words are on pages 153–156.
  • Providers can join or leave a plan’s provider network anytime during the year. Your plan can also change the providers in the network anytime during the year. If this happens, you may need to choose a new provider.
  • If you join a clinical research study, some costs may be covered by Original Medicare and some may be covered by your Medicare Advantage Plan.
  • Medicare Advantage Plans can’t charge more than Original Medicare for certain services, like chemotherapy, dialysis, and skilled nursing facility care.
  • Medicare Advantage Plans have a yearly limit on your out-of-pocket costs for medical services. Once you reach this limit, you’ll pay nothing for covered services. This limit may be different between Medicare Advantage Plans and can change each year. You should consider this when choosing a plan.