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What is a Medicare Advantage Plan?

The Medicare Advantage plan is also known as Medicare Part C is a private insurance option that contracts with Medicare to provide you with all of your Part A and Part B benefits.  Medicare Advantage Plans include Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee For Service (PFFS), Special Needs Plans and Medicare Medical Savings Accounts Programs.  Once someone is enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid under Original Medicare.

Medicare Advantage Plans cover all Medicare services; they may also offer extra coverage, such as prescription drug coverage.  Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans.  These companies must follow rules set by Medicare.  However, each Medicare Advantage Plan can charge different out-of-pocket costs.  Each plan can also have different rules for how you get services, such as:

  • Whether you need a referral to see a specialist

  • If you are required to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care

It is important to note these rules can change each year.

The Medicare Advantage PPO Plan

A Medicare Advantage PPO is a type of Medicare Advantage Plan (Part C) offered by an insurance company.  In a PPO Plan, you pay less if you use doctors, hospitals, and other health care provided that belong to a plan’s network.  You can expect to pay more if you use doctors, hospitals, and providers outside of the network.

The Medicare Advantage HMO Plan

​A Medicare Advantage HMO is another type of Medicare Advantage Plan (Part C) offered by an insurance company.  In most HMO Plans, you can only see doctors, other health care providers, or hospitals on the plan’s list except in an emergency.  You may also need to get a referral from your primary doctor to see a specialist.  It is important to follow the plan’s rules (such as obtaining prior approval for certain services) because should you obtain healthcare outside the plan’s network, you may have to pay the full cost.

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