Types of Medicare Advantage Plans
Differences in Plans
There are a variety of Medicare Advantage Plans, each with different types of coverage and benefits. Choosing a plan that suits your health needs is critical.
Health Maintenance Organization (HMO)
HMOs are a type of Medicare Advantage plan that typically limit coverage to hospitals, doctors, and other providers that have agreements with the plan (except in emergencies). However, there are certain types of HMO plans, called HMO Point-of-Service (HMOPOS) plans, that cover some services out-of-network. It is also common for HMO plans to require a referral from a primary care physician before seeing a specialist. Additionally, individuals that have an HMO Medicare Advantage plan cannot have a separate Part D Plan.
|
HMO Plan Features |
|
|---|---|
Monthly Premium |
Rarely |
Drug Coverage |
Usually |
Out-of-Network Coverage |
Rarely |
Referral for Specialist |
Usually |
Preferred Provider Organization (PPO)
PPO plans are another type of Medicare Advantage plan that have a network of health care providers that offer better coverage for services. But, a PPO network is typically larger than that of an HMO. Additionally, with a PPO, patients can receive partial coverage for out-of-network services and often do not require a referral to see a specialist. However, it is worth noting that the increased freedom of a PPO plan usually comes with an increased premium. Also, like an HMO plan, individuals cannot have separate Part D coverage. PPO Medicare Advantage plans are available in local or regional (RPPO) areas.
|
PPO Plan Features |
|
|---|---|
Monthly Premium |
Rarely |
Drug Coverage |
Usually |
Out-of-Network Coverage |
Usually |
Referral for Specialist |
NO |
Special Needs Plan (SNP)
Medicare SNPs are a type of Medicare Advantage plan that limits membership to individuals with specific diseases or characteristics. Medicare SNPs tailor benefits, providers, and drug formularies to best meet the specific needs of the groups they serve. Eligible individuals can join SNPs at any time. SNP membership is limited to those meeting the criteria of any of the following groups:
- Residents of institutions (like a nursing home) or in need of nursing care at their home
- Individuals eligible for both Medicare and Medicaid
- Patients diagnosed with certain chronic or disabling conditions, such as:
- Diabetes
- End-Stage Renal Disease (ESRD)
- HIV/AIDS
- Chronic Heart Failure
- Dementia
Plans may further limit membership, but should coordinate the services and providers you need to help you stay healthy and follow doctor’s or other health care provider’s orders.
|
SNP Plan Features |
|
|---|---|
Monthly Premium |
NO |
Drug Coverage |
YES |
Out-of-Network Coverage |
Rarely |
Referral for Specialist |
Usually |
