A Medicare managed care plan is one type of Medicare Advantage plan. The term “managed care plan” generally refers to HMO (health maintenance organization), PPO (preferred provider organization) or POS (point of service) plans. These Medicare Advantage plans offer managed care that is coordinated between health care providers within a network.
The opposite of a managed care plan would be a Medicare PFFS (private fee for service) plan. These plans do not utilize a primary care physician or require referrals to see specialists, and they generally do not include a network of health care providers.
How managed care plans work
As a member of a managed care plan, a beneficiary will typically see a primary care physician for any illnesses, injuries or conditions. When possible, the primary care physician will treat the patient.
If the primary care physician is unable to administer the necessary treatment, they will refer the patient to a specialist, typically within the plan’s network. A managed care plan fosters a more team-oriented approach to the beneficiary’s health.
There are some advantages to using a managed care plan:
- Seeing a primary care physician allows patients to build a rapport with their doctor, and the doctor gets to know the patient’s health history firsthand.
- When a patient is referred to a specialist, there is communication between the primary care physician and the specialist regarding the patient’s health and treatment. A patient’s medical records are typically transferred between providers in the network for increased communication.
- The increased coordination allows primary care physicians and other providers within the network to make more informed decisions regarding a beneficiary’s care.
- The networks of managed care plans often include pharmacies, which can help make ordering and filling prescriptions faster and easier for everyone involved.
- There’s less uncertainty about a beneficiary’s costs for care in a managed care plan, provided they stay within the assigned network for qualified services.
Types of Medicare managed care plans
As previously mentioned, managed care plans can include a few different types of Medicare Advantage plans.
- Health maintenance organization (HMO)
In a Medicare HMO plan, you use a primary care physician to coordinate your care, and you receive services from a network of health care providers that partner with your plan. - Preferred provider organization (PPO)
In a Medicare PPO plan, you may or may not use a primary care physician, and you are typically not required to get a referral to see a specialist. You’ll have a network of providers from which to choose .You will generally can receive at least some coverage when receiving care outside of the network of providers, though your health care services may cost more than if you received them from a provider within your plan network. - Point of service (POS)
You can use a primary care physician in a Point of Service plan, as you would with an HMO plan. But as with a PPO plan, you can go outside of the plan network and still receive some coverage for services, though you may pay higher out-of-pocket costs than if you selected an in-network provider.
How can I enroll in a Medicare managed care plan?
For more information about managed care plans or other types of Medicare Advantage plans, including plan benefits, eligibility, enrollment and availability, contact a licensed insurance agent by calling TTY Users: 711 24 hours a day, 7 days a week.
