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Medicare Advantage Plans

Medicare Advantage plans include:
  • Health Maintenance Organizations (HMO)
  • Preferred Provider Organizations (PPO)
  • Private Fee-for-Service Plans (PFFS)
  • Medicare Special Needs Plans (SNP)

These plans may cover more services and have lower out-of-pocket costs than the Original Medicare Plan. If you join one of these plans, you generally get all your Medicare-covered health care through that plan. Some plans cover prescription drugs. In some plans, like HMOs, you may only be able to see certain doctors or go to certain hospitals to get covered services.

To join a Medicare Advantage plan, you must have Medicare Part A and Part B. You will have to pay your monthly Medicare Part B premium to Medicare. In addition, you might have to pay a monthly premium to your Medicare Advantage Plan for the extra benefits they offer.

Enrollment Periods

For most people, the election time period for Medicare Advantage is November 15, 2009 March 31, 2010, which includes the Annual Election Period (November 15, 2009 December 31, 2009) and the Open Enrollment Period (January 1, 2010 March 31, 2010). If you do not currently have Part D coverage, and you want to enroll in a Medicare Advantage plan that provides Part D coverage, you must select a plan before December 31, 2009 in order to have Part D coverage for 2010.

If you already have Part D coverage, and you want to enroll in or switch to a Medicare Advantage plan that provides Part D coverage, you have until March 31, 2010 to make your decision.

Types of Medicare Advantage Plans

Health Maintenance Organizations (HMO)
These plans usually require that you sign up for a certain network of health care providers. It may be one hospital or a group of doctors and other providers. You choose one doctor to be your primary care physician. In order to see a specialist, you may need a referral from your doctor. HMO plans will cover emergency services if you have an accident and are unable to reach your network doctors. If, however, you choose to see a doctor who is not in the network for a non-emergency situation, you may have to pay for that visit yourself.

Preferred Provider Organizations (PPO)
PPOs work a lot like the HMO plans. Generally, you pay less if you receive your care from a doctor who is within the PPO network. When you sign up, you're given a list of health care providers within the network. Unlike with many HMOs, you don't need a doctor's referral to see a specialist under a PPO Plan. You can see any doctor or provider who accepts Medicare. If you do choose a provider who is not in the plan, you will usually pay more for their services than you would for a network provider.

Private Fee-for-Service Plans (PFFS)
These plans offer a wider degree of freedom in choosing your health care options. You can go to any doctor or hospital that accepts the plan's terms and conditions of payment. You may get extra benefits, such as additional days in the hospital. The coverage comes through a private insurance company. The company decides how much they pay for any given service and what portion you will pay.

Some Medicare PFFS plans offer Medicare prescription drug coverage. If your Medicare PFFS plan doesn't offer Medicare prescription drug coverage, you can join a Medicare Prescription Drug Plan to get this coverage.

Medicare Special Needs Plans (SNP)
These plans are designed to cover certain groups with special needs. Those groups with coverage are as follows:

  1. People in designated long-term care facilities
  2. People who are eligible for both Medicare and Medicaid
  3. People with certain chronic or disabling conditions.

Generally, these plans offer lower copayments and more benefits than the Original Medicare. They are also required to provide prescription drug coverage.

H3916_S5593_12_0824 CMS Approved This page last updated 1/18/2013

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The information contained on this website regarding the Patient Protection and Affordable Care Act of 2010 (“PPACA”), as amended, and/or any other law, does not constitute legal or tax advice and is subject to change based upon the issuance of new guidance and/or change in laws.

The information provided is intended to provide general information only and does not attempt to give you advice that relates to your specific circumstances. State laws and regulations governing health insurance and health plans may vary from state to state. Further, any information regarding any health plan will be subject to the terms of its particular health plan benefit agreement and some health plans may not be available in every region or state.

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