Medicare Advantage Plans

Conditions:

• You have Part A & Part B
• You live in a plans service area
• You’re a U.S. citizen, national, or lawfully present in the U.S.
• You don’t have End-Stage Renal Disease, with few exceptions

Exceptions:

• If you were already enrolled in a medicare advantage plan when you develop end stage renal disease
• If you’re in an medicare advantage plan with end stage renal disease and your medicare advantage plan leaves your area, you have a one-time right to join another medicare advantage plan
• If you have an employer or union health plan or other health coverage through a company that offers one more medicare advantage plans you may be able to join
• If you’ve had a successful kidney transplant, you may be eligible
• You may be able to join a medicare special needs plan that covers end stage renal disease if one is available in your area.

Costs for medicare advantage plans vary based on your provider. However, here are the primary factors that influence your cost: 

• Whether the plan charges a monthly premium, you’ll pay this in addition to your part B premium.
• Whether the plan has a yearly deductible or any addition deductibles for certain services.
• Copayment and coinsurance costs
• The type of health care services you need and how often you get them.
• Whether you get services from a network provider or a provider that doesn’t contract with the plan.
• Whether the plan offers extra benefits and if you need to pay an extra premium for them.
• The plans yearly limit on out-of-pocket costs.
• Whether you have Medicaid or get help from your state.

HMO: Health Maintenance Organization Plan 

• This is a network-based medicare advantage plan. This means you will have a limited selection of providers within that network.
• Prescription drug coverage is included in most cases, but make sure when you sign up.
• You will most likely need to choose a primary care doctor with this type of plan.
• If your health care provider leaves your network, you will be notified and have an opportunity to pick a new primary care physician.
• It’s important to follow the plans rules, some services may need prior approval.
• Be sure to check with your plan about any other rules or conditions that may apply to you.

PPO: Preferred Provider Organization Plan

• PPO plans have networks like HMO’s, but they are usually a bit more flexible.
• Prescription drug coverage is usually provided. Be sure to check with your PPO provider to be sure.
• You will generally not need to choose a primary care doctor.
• In most cases you will not need a referral to see a network specialist.
• These plans generally offer more coverage than available through Original Medicare but are also generally more expensive.

PFFS: Private Fee-For-Service Plan

• With this type of plan, you can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plans payment terms and agrees to treat you.
• Some PFFS Plans have networks, others do not. Costs will vary between in network and out of network providers with these kinds of plans.
• Some in network providers will always treat you even if you’ve never been treated there before due to network agreements.
• Some out of network providers may decide not to treat you even if they’ve treated you before.
• You will not need to choose a primary care doctor.
• You will not need to get a referral to see a network specialist.
• These aren’t the same as Original Medicare or Medigap coverage.
• The plan decides how much you pay for services.
• For each service you get, make sure to show your plan member card before treatment.
• In a medical emergency doctors, hospitals, and other providers must treat you.

SNP: Special Needs Plan

These types of plans limit themselves to these specific groups:
• People who live in certain institutions, like nursing homes, or who require nursing care at home OR
• People who are eligible for both Medicare & Medicaid OR
• People who have specific chronic or disabling conditions (such as HIV, or end stage renal disease.)
• Plans may limit membership further if they choose
• Your plan will coordinate the services and providers you need to help you stay healthy and follow doctors’ or other health care providers’ orders.
• Generally, these plans do have networks that you MUST stay within, unless you have a medical emergency.
• All SNP plans must provide Medicare prescription drug coverage.
• You will need to choose a primary care doctor in most cases.
• In most cases you will need a referral to see a network specialist.