If you or a loved one have recently applied for Medicare Part A (inpatient hospital insurance) and Part B (outpatient services by a doctor or other healthcare professional), you have a basic understanding of what coverage Medicare offers.
Did you know that Medicare Advantage plans, also known as Part C or MA Plans, are another way to get Part A and Part B coverage, plus additional benefits such as dental care, eyeglasses, wellness programs, and, in some cases, Part D prescription coverage?
Medicare Advantage plans are offered by Medicare-approved private companies that, in most cases, require you to use healthcare providers who participate in the plan’s network. Some offer nonemergency coverage out of network, but usually at a higher cost. As such, these plans set a limit on what you must pay out-of-pocket each year for covered services.
Choosing the Medicare Advantage Plan That’s Right for You
There are four types of Medicare Advantage plans. These include the following:
Health Maintenance Organization (HMO) Plans
With an HMO plan, you generally receive care and services from doctors and other healthcare providers, and hospitals that are within the plan’s network. Notable exceptions include emergency care, out-of-area urgent care, and temporary out-of-area dialysis. HMO Point-of-Service plans may allow you to receive some service out-of-network for a higher co-pay or co-insurance.
In most cases, you must choose a primary care physician (PCP) when choosing an HMO plan. Also, you’ll need a referral from your PCP to see a specialist in your HMO plan. Most HMO plans cover prescription drugs, but if you want drug coverage (Part D), you need to join an HMO that offers such coverage. Also, if you join an HMO plan that doesn’t offer drug coverage, you cannot join a separate Medicare drug plan.
With an HMO plan, if you seek healthcare outside the plan’s network, you may have to pay the full cost of service.
Preferred Provider Organization (PPO) Plans
These plans have network doctors, hospitals, and other healthcare providers. If you use those that belong to the plan, you pay less for services. However, you are not required to choose a primary care physician and you can also use out-of-network providers, usually at a higher cost. You are also covered for emergency and urgent care.
In most cases, prescription drug coverage is offered in PPO plans. If not and you join, you cannot join a Part D Medicare drug plan. You don’t need a referral to see a specialist under a PPO plan, but covered services are usually lower if you see an in-network doctor. You can also save money by using “preferred” providers.
Private Fee-for-Service (PFFS) Plans
Although it is a type of Medicare Advantage plan offered by a private insurance company, a PFFS plan isn’t the same as original Medicare or Medigap coverage. The PFFS plan determines how much must be paid to doctors, hospitals, and other healthcare providers for services, and how much of that expense will be your responsibility.
You do not need to choose a primary care provider in a PFFS plan, nor do you have to get a referral to see a specialist in the plan. In certain cases, you can receive care from any doctor, hospital, or healthcare provider with a PFFS plan. If the plan has a network of providers, you can see any who have agreed to treat plan members. But if you visit a provider or facility that doesn’t belong to the plan’s network for non-emergency or non-urgent care, your plan may cover services, or your costs could be higher.
PFFS plans may or may not cover prescription drugs. If not, you can join a separate Medicare Part D drug plan to receive coverage.
Special Needs Plans (SNPs)
These plans are limited in membership to people with specific diseases or characteristics. This includes those who live in nursing homes or communities within-home nursing care; those eligible for both Medicare and Medicaid; and those with chronic or disabling conditions, such as diabetes, end-stage renal disease, HIV/AIDS, chronic heart failure, or dementia. Benefits, provider choices, and covered prescription drugs are tailored to meet the needs of those served.
Some SNPs cover out-of-network services, while others don’t. SNPs typically include specialists in the diseases or conditions affecting their members. Also, some SNPs require referrals, while others don’t. However, all SNPs provide Part D Medicare drug coverage.
Doctor’s Medicare Advantage Plans in Miami, Florida
At Palm Medical Centers, our team of board-certified primary care physicians works with most Medicare health plans to make excellent healthcare accessible to you and your loved ones. Find out which medical plans we accept. Or please contact the Palm Medical Center nearest you for more information.
We have 22 medical centers located throughout South Florida and Central Florida and you can reach us by calling (833) 500-PALM (7256).