Medicare Advantage

It is important to note that Medicare Advantage plans vary by location and coverage can change annually. It is important to review and compare the plan’s summary of benefits and compare it to your current health situation and needs. It’s also important to check the network of providers of the plan and make sure that your current providers are in the network.

High Maintenance Organization

One of the main differences between Original Medicare and Medicare Advantage HMO plans is that HMOs typically require you to use a network of providers. This means that you will only be able to see doctors and other healthcare providers that are part of the HMO’s network. If you see a provider outside of the network, you will likely have to pay more for the services you receive. However, some plans provide out-of-network coverage to a certain extent.

In a Medicare Advantage HMO plan, you are typically required to choose a primary care physician (PCP) who will act as your main point of contact for healthcare services. This means that you will need to see your PCP for most of your healthcare needs, such as routine check-ups and referrals to specialists.

Your PCP is responsible for coordinating your care and making sure that you get the services you need. They will also be the first point of contact when you have any health concerns or questions. If you need to see a specialist, your PCP will usually need to provide a referral before you can make an appointment.

It is important to choose a PCP that is part of the HMO’s network and that you feel comfortable. You should also consider factors such as the PCP’s location, availability, and the quality of care they provide.

Another difference between Original Medicare and Medicare Advantage HMO plans is that HMOs often offer additional benefits such as vision, hearing, and dental coverage, as well as prescription drug coverage. These additional benefits are not typically included in Original Medicare.

When enrolling in a Medicare Advantage HMO plan, you will still need to pay your Medicare Part B premium. However, the plan may have additional costs or deductibles that you will need to pay. These costs can vary depending on the plan you choose and the coverage it provides.

Preferred Provider Organization

With a PPO plan, you have the flexibility to see any provider that accepts Medicare, but you may pay less out-of-pocket costs if you choose providers within the plan’s network. PPO plans also typically have annual limits on out-of-pocket costs, which can provide some protection against high medical expenses. 

With a Medicare Advantage PPO plan, you typically do not need to choose a primary care physician (PCP). Instead, you have the freedom to see any provider who accepts Medicare, within the plan’s network, without the need for a referral. However, some PPO plans may require you to choose a PCP or have a PCP who coordinates your care. It is best to check with your specific plan to see if they require a PCP and if there are any restrictions on seeing specialists without a referral. It is also important to note that, while you don’t have to select a primary care physician, it can be beneficial to have one. Your PCP can help you coordinate your care, ensure you get all the preventive services you need, and keep track of your health history and medications.

It typically has a maximum out-of-pocket limit, which is the most you will have to pay for covered medical expenses in a year. Once you reach this limit, the plan will cover all remaining covered medical expenses for the rest of the year. The maximum out-of-pocket limit for a PPO plan can vary, but it cannot exceed the limit set by Medicare. In 2023, the maximum out-of-pocket limit for Medicare Advantage plans is $8300.

Private Fee For Service Plans

With a PFFS plan, you have the freedom to see any provider who accepts the plan’s terms and conditions. The provider must agree to the plan’s payment terms and accept the plan’s approved amount as full payment for covered services. This means that you don’t have to choose a primary care physician (PCP) and don’t need referrals to see specialists. However, it’s important to note that some providers may not accept the plan’s terms and conditions and may not be covered under the plan.

One of the biggest differences between PFFS plans and other Medicare Advantage plans is that those plans are not required to have a network of providers. This means that you may not have as much access to providers as you would with a PPO or HMO plan. However, they are required to have a process for resolving disputes between beneficiaries and providers regarding overpayment for services.

They also typically have higher out-of-pocket costs than other types of Medicare Advantage plans. The plan may require you to pay a higher deductible, co-payments, or coinsurance than other types of plans. Additionally, PFFS plans typically have higher premiums.

Another important aspect to consider is that they can change the terms and conditions of their plan, including the providers that accept it, at any time, and may also terminate their contract with Medicare at the end of the year. This means that you may have to switch plans or providers if your current plan or provider is no longer available.

Special Needs Plans

Special needs plans (SNPs) are a type of Medicare Advantage plan that is specifically designed for people with certain chronic conditions or special needs, such as people who have both Medicare and Medicaid, or who live in a nursing home. These plans typically provide additional benefits and services that are not typically covered by Original Medicare, such as transportation to medical appointments and additional coverage for prescription drugs. They may also have lower out-of-pocket costs. However, SNPs may have stricter rules for enrollment and may only be available in certain areas. It is important to note that not all SNPs cover all chronic conditions or special needs, so it is important to carefully review the plan’s coverage and benefits before enrolling.

Several types of Special Needs Plans (SNPs) are available to individuals who are eligible for Medicare. These include:

• Institutional SNPs: These plans are designed for individuals who live in a nursing home or other long-term care facility. They provide coverage for the services and benefits that are typically needed by individuals in these settings.
• Dual Eligible SNPs: These plans are designed for individuals who have both Medicare and Medicaid coverage. They provide additional benefits and services that are not typically covered by Original Medicare, such as prescription drug coverage and transportation to medical appointments.
• Chronic Condition SNPs: These plans are designed for individuals who have specific chronic conditions, such as diabetes, heart failure, or chronic obstructive pulmonary disease (COPD). They provide additional benefits and services that are tailored to the specific needs of individuals with these conditions, such as additional coverage for prescription drugs and care management services.
• Medicaid SNPs: These are designed for individuals who are eligible for Medicaid and Medicare, and are designed to coordinate the benefits of both programs to help you get the care you need.

Medical Savings Account Plans

Medicare Medical Savings Account (MSA) plans are a type of Medicare Advantage plan that combines a high-deductible insurance plan with a savings account. The savings account is used to pay for medical expenses, and any unused funds roll over from year to year. These plans are typically less expensive than traditional Medicare Advantage plans, but they also have higher out-of-pocket costs. 

 The money in the savings account can also be used to pay for certain other expenses, such as prescription drugs. As already said, funds in the savings account roll over from year to year, and any unused funds can be withdrawn and used for non-medical expenses after you turn 65.

It’s important to note that those plans typically have more limited networks of doctors, hospitals, and other providers than traditional Medicare Advantage plans. Additionally,  they may not cover certain services that are covered by Original Medicare, such as preventive care.

Point Of Service Plans

Medicare Point-of-Service (POS) plans are a type of Medicare Advantage plan that combines features of both HMOs and PPOs. Like HMOs, POS plans typically require you to choose a primary care physician and get referrals to see specialists. However, unlike HMOs, POS plans also allow you to see out-of-network providers, but typically at a higher cost. POS plans may also have more flexibility in terms of where you can receive care, such as allowing you to receive care from out-of-network providers or at out-of-network facilities.

Medicare Advantage Enrollment Periods

The enrollment periods for Medicare Advantage plans include the Initial Enrollment Period (IEP), Annual Enrollment Period (AEP), Open Enrollment Period (OEP), and Special Enrollment Period (SEP).

The IEP is a seven-month window starting three months before the individual’s 65th birthday, including the birthday month, and ending three months after the birthday month, in which one becomes eligible for Medicare for the first time.

The AEP is an annual window from October 15 to December 7, during which individuals can make changes to their current Medicare Advantage plan or switch to a different plan.

The OEP is a period from January 1 to March 31 each year, in which individuals already enrolled in a Medicare Advantage plan can switch to a different plan or return to Original Medicare.

The SEP is an opportunity for individuals who experience certain life events such as moving out of the plan’s service area, losing employer coverage, or Medicaid eligibility to enroll in a Medicare Advantage plan outside of the regular enrollment periods.

Medicare Advantage Costs

In addition to the standard Medicare Part B premium, individuals enrolled in MA plans may also have to pay additional costs such as monthly plan premiums, deductibles, copays, and coinsurance.

The cost of a MA plan can vary depending on the plan and the area in which the individual lives. Some plans may have $0 monthly premiums, while others may have premiums that are higher than the standard Medicare Part B premium.

Deductibles, copays, and coinsurance can also vary depending on the plan. Some plans may have no deductibles, while others may have deductibles that are higher than the standard Medicare Part A and Part B deductibles. Copays and coinsurance can also vary depending on the plan and the services that are covered.

It is important to note that MA plans may also have out-of-pocket maximums, which limit the amount that an individual has to pay for covered services in a year (8300$ in 2023). This can provide some financial protection for individuals who have significant healthcare expenses.

Additionally, some MA plans also offer additional benefits not covered by Original Medicare, such as vision, hearing, and dental coverage, and it is important to compare the benefits and costs of different MA plans before enrolling.