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Medicare Advantage

Medicare Advantage - Medicare Part C (MA or MAPD)

Medicare Advantage plans combine all the benefits of Medicare Parts A and B and can include Medicare Part D. (MA) plans are available to individuals entitled to Medicare Part A and enrolled in Medicare Part B due to age or disability.

 

This means they are available to people under age 65. You must live within the service area of the plan. They are offered by private insurance companies and offer low or zero premiums plans in addition to the Medicare Part B premium.

 

Medicare Advantage plans have copays or coinsurance for services as well as a maximum out of pocket (MOOP) for the plan year. Many also include vision, dental, hearing, gym discounts or memberships and OTC benefits.

Health Maintenance Organization (HMO) or (HMO-POS)​

  • Requires you to use in-network doctors for services unless an emergency

  • You choose a Primary Care Doctor (PCP) that manages your care

  • Referrals required by your PCP to see specialists

  • Some plans offer out of network doctors. This is called a point-of service option (POS).  You will usually pay a higher coinsurance for services out of network.

 

  • Prior Authorization maybe required for services.

Preferred Provider Organization (PPO)

  • You will have lower copays or coinsurance with the use of in-network providers

  • These plans give you the flexibility to use out-of-network doctors and facilities at a higher copay or coinsurance.

  • Prior Authorization maybe required for services.

Private-Fee-For-Service (PFFS)

  • PFFS plans are different from other types of MA plan. Beneficiaries can seek health care from any Medicare doctor, or hospital that agrees to the plan’s payment terms and grants treatment of services.

  • Nevertheless, not all doctors will accept the PFFS plan’s payment terms.

  • Of course, the cost will be higher; but you have options for out-of-network health care doctors and hospitals if they agree with the plan’s terms. PFFS plans may cover the costs of prescription drugs; if not, you may enroll in a Part D Plan.

  • PFFS Plans don’t require choosing a primary care doctor; certain PFFS Plans have arrangements with a specific network of doctors.

  • In contrast, out-of-network doctors and hospitals can choose not to treat you in non-emergency situations. For emergencies, hospitals, and other health care doctors may not refuse you treatment.