Different Types of Medicare Advantage Plans

There are three main types of Medicare Advantage plans. They are:

1. Health Maintenance Organization, often referred to as an HMO plan
   
   
2. Preferred Provider Organizations or PPO plan
   
   
3. Medicare Private-Fee-for-Service plan is offered in limited parts of the United States
   
   

Question Summary

1. What is the difference between a PPO and a HMO?
   
   
2. Why it's important to know if your health provider accepts Medicare?
   
   
3. Why it's important to know if your provider wil bill your health provider

Health Maintenance Organization – HMO

With a HMO, you will need to choose your primary care physician at enrollment. Additionally, you very likely will be required to get a referral from your primary physician when / if you want to see a specialist. Other than an emergency there is no coverage outside of the plan’s network. The benefit is that you have lower out of pocket expenses as long as you stay within the plan’s coverage network.

Preferred Provider Organization – PPO

You do not need to pick a primary care physician or get referrals if you need to see a specialist as you do with an HMO. If your provider accepts Medicare and agrees to bill your plan, you are not limited to your network. It is important to note that a provider might accept Medicare however not agree to bill your provider, so it’s important to confirm prior to any treatment.

Private Fee-for-Service (PFFS) Plans

A Medicare PFFS Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PFFS plans aren’t the same as Original Medicare or Medigap. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.

 A Quick Recap

  ✔  You must be enrolled in Medicare Part A and Part B in order to enroll in a Medicare Advantage Plan

  ✔  You must live in the Medicare Advantage plan's service area