A type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all of your Part A and Part B benefits. Medicare Advantage Plans include:
- Health Maintenance Organizations
- Preferred Provider Organizations
- Private Fee-for-Service Plans
- Special Needs Plans
- Medicare Medical Savings Account Plans
If you’re enrolled in a Medicare Advantage Plan:
- Most Medicare services are covered through the plan
- Medicare services aren’t paid for by Original Medicare
Most Medicare Advantage Plans offer prescription drug coverage.
Health Maintenance Organization (HMO)
In most HMO Plans, you generally must get your care and services from providers in your plan’s network, like:
- Other health care providers
You may also need to get a referral from your primary care doctor.
In HMO Plans, you generally must get your care and services from providers in the plan’s network, except:
- Emergency care
- Out-of-area urgent care
- Out-of-area dialysis
In some plans, you may be able to go out-of-network for certain services. But, it usually costs less if you get your care from a network provider. This is called an HMO with a point-of-service (POS) option.
In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want Medicare prescription drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage.
What else do I need to know about this type of plan?
- If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.
- If you get health care outside the plan’s Network , you may have to pay the full cost.
- It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.
Preferred Provider Organization (PPO)
How PPO Plans Work
A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C)offered by a private insurance company. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s Network. You pay more if you use doctors, hospitals, and providers outside of the network.
Can you get your health care from any doctor, other health care provider, or hospital?
In most cases, you can get your health care from any doctor, other Health care provider, or hospital in PPO Plans. PPO Plans have network doctors, other health care providers, and hospitals.
Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren’t on the plan’s list, but it will usually cost more.
Are prescription drugs covered?
In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn’t offer prescription drug coverage, you can’t join a Medicare Prescription Drug Plan (Part D).
Do you need to choose a primary care doctor?
You don’t need to choose a primary care doctor in PPO Plans.
Do you have to get a referral to see a specialist?
In most cases, you don’t have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.