Each type of Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plan has different network A network is a group of doctors, hospitals, and pharmacies that contract with a Medicare Advantage Plan to provide health care services. Generally, plan members will have the lowest costs when using providers and facilities in the plan’s network. Networks may be made up of both preferred and non-preferred providers. rules. A network is a group of doctors, hospitals, and medical facilities that contract with a plan to provide services. There are various ways a plan may manage your access to specialists or out-of-network Out-of-network means not part of a private health plan’s network of health care providers. If you use doctors, hospitals, or pharmacies that are not in your Medicare Advantage Plan or Part D plan’s network, you will likely have to pay the full cost out of pocket for the services you received. providers. Remember that your costs are typically lowest when you use in-network In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers. providers and facilities, regardless of your plan.
It’s important to know that not all Medicare Advantage Plans—even plans of the same type—work the same way. Make sure you understand a plan’s network and coverage rules before enrolling. If you have questions, contact your plan for more information.
| General overview of provider access rules | ||
|---|---|---|
Do I need to get a referral before I can see an in-network specialist? |
Can I go to a doctor or hospital that is not in the plan’s network? |
|
HMO |
Yes, usually |
No, unless you need urgent or emergency care of if you have a Point of Service (POS) option that allows you to use out-of-network providers |
PPO |
No |
Yes, but you will pay more unless it is an emergency |
PFFS |
Yes |
Yes, but you will usually pay more and the provider must agree to treat you, unless it is an emergency |
Note: This chart does not include Special Needs Plans (SNPs) or Medicare Medical Savings Account (MSA) Medicare Medical Savings Account (MSA) plans are a type of Medicare Advantage Plan that includes both a high deductible health plan and a bank account to help pay your medical costs. The plan deposits funds into the bank account once each year to use for your medical expenses, but the amount is generally lower than the full deductible. MSA plans cannot offer Medicare prescription drug coverage (Part D). plans. A SNP is managed care plan that serves people with special needs. In an MSA plan, you can go to any doctor or hospital willing to accept the plan’s fees. If you are considering joining a SNP or an MSA, ask about that specific plan’s network rules.