Part C

What Are the Different Types of Medicare Advantage Plans?

Every Medicare Advantage plan must offer the same set of basic benefits, and many plans provide additional benefits such as prescription drug coverage or wellness programs.

In 2021, there are a total of 3,550 different Medicare Advantage plans available in the United States, according to the Kaiser Family Foundation (KFF).1

Plan options vary around the country, so where you live could affect your plan options.

What do different Medicare Advantage plans cover?

Every Medicare Advantage plan must offer the same set of basic benefits as Medicare Part A and Part B, and many plans may also provide additional benefits such as prescription drug coverage or wellness programs.

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The benefits you get will depend on the individual plan you enroll in, so you need to compare plans to get the right coverage for your needs.

Narrowing down your options may be difficult. The first step is to determine which of the 5 major types of Medicare Advantage plans most closely fit your health insurance needs.

Types of Medicare Advantage plans

There are 5 major types of Medicare Advantage plans. The major types of plans differ by network restrictions, referral requirements, and prescription drug coverage options.

Health Maintenance Organization (HMO) plans

HMO plans offer low-cost coverage options with network restrictions.

If you have an HMO, you will be covered only for medical providers and hospitals within the HMO’s specific network, unless it’s emergency or urgent care. If you go out of your network for care, your insurer might not pay for it. The provider networks are grouped based on ZIP codes or county lines.

In most cases, HMOs require you to pick a primary care physician, and you will need a referral to see a specialist in most cases.

Most HMO plans provide prescription drug coverage.

There also is a less common version of HMO plans called HMO Point of Service plans (HMOPOS). HMOPOS are basically structured like an HMO but allow access to some out-of-network health care services for an additional cost.

Preferred Provider Organization (PPO) plans

PPO plans offer coverage through a network of providers, but you are allowed to access out-of-network care for covered services, usually for a higher cost. If you go to doctors and hospitals in the plan's network, you will generally pay less.

You do not need to choose a primary care doctor with a PPO, and usually you do not need a referral to see a specialist.

Most PPO plans provide prescription drug coverage. However, if the plan lacks drug coverage, you cannot join a Medicare Part D prescription drug plan. If you want Medicare drug coverage, you must join a PPO plan that offers prescription drug coverage.

PPO plans operate both locally and regionally, depending on the specific plan. Local PPO plans are grouped into smaller areas such as counties. Regional PPO plans provide coverage in entire states or multi-state areas.

Most PPO plans are regional.

Private Fee-for-Service (PFFS) plans

You might consider signing up for a Medicare PFFS plan if you are interested in having some flexibility in your health care choices. 

With PFFS plans, you may go to any Medicare-approved doctor or health care facility that has accepted the plan's payment terms and agreed to treat members of your Medicare Advantage plan. You will be treated in an emergency even if the health care provider has not agreed to your plan’s terms.

Some PFFS plans may use a provider network. If you enroll in one of these plans you can also see any of the network providers who’ve agreed to always treat plan members. If you choose to  visit an out-of-network provider who accepts the plan’s terms, you may face extra charges.

You do not need to choose a primary care doctor with PFFS plans, and you do not need a referral to see a specialist.

Some PFFS plans offer prescription coverage. If your plan does not offer coverage, you can join a Medicare Part D plan. Check with the plan for more information.

Special Needs Plans (SNPs)

SNPs are only available to Medicare beneficiaries with specific diseases, health conditions or financial circumstances. The plans are structured to benefit their members according to their health needs.

SNPs limit membership to those with chronic or disabling conditions like dementia and HIV/AIDS or those living in institutions such as nursing homes. The plans are tailored for these members to provide the most suitable benefits, providers, and drug formularies for the group.

With an SNP, you need to visit in-network doctors and hospitals, unless you need emergency or urgent care or in other limited situations.

The plans usually require that you have a primary care doctor or a care coordinator. In addition, you will usually need a referral to see a specialist.

All SNPs must provide prescription drug coverage.

Medical Savings Accounts

Medical Savings Accounts provide you with a high-deductible health care plan and a bank account. Medicare will deposit money into the account and you can use the money to pay for your health care services throughout the year.

MSAs cover all of the required Medicare services and can provide additional benefits such as vision and dental coverage.

MSAs do not include prescription drug coverage. If you need coverage, you must join a Medicare prescription drug plan.

To learn more about Medicare Advantage plans and to find plans in your area, call a licensed insurance agent today or compare plans online.

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1 Fugelsten Biniek, J. et al. (Oct. 29, 2020). Medicare Advantage 2021 Spotlight: First Look. Kaiser Family Foundation. Retrieved from www.kff.org/issue-brief/medicare-advantage-2021-spotlight-first-look.

Christian

About the author

Christian Worstell is a licensed insurance agent and a Senior Staff Writer for MedicareAdvantage.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options.

His work has been featured in outlets such as Vox, MSN, and The Washington Post, and he is a frequent contributor to health care and finance blogs.

Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism. He currently lives in Raleigh, NC.

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