Medicare HMO plans are a type of coordinated care in which you will choose a primary care doctor in the network. You usually must get a referral from that doctor before you can see a network specialist.
Medicare HMO plans often have the lowest monthly premiums of the three types of Medicare Advantage programs. This is because they are generally the most restrictive, requiring a primary care physician. Members visit their PCP first to obtain a referral before they can see a specialist.
Medicare PPO plans are also coordinated care plans but are generally more flexible than Medicare HMO plans. Members can see usually see any doctor in the network without a referral. You can also treat outside the network, although you will spend more to do so.
Always check the rules of your specific plan, which can be found in the plan’s Summary of Benefits.
Medicare PFFS (Private-Fee-for-Service) plans generally have no network or a very small network. You can see any doctor who will bill the plan as long as they agree to the plan’s terms and conditions up front. This puts the burden on you to ask your providers whether they will accept the plan before you seek medical services. These plans have been phased out in many counties where at least 2 other plan types exist.
In some service areas, there may be less common plan types also available.
Special Needs Plans (SNPs) are available only to Medicare beneficiaries with certain health conditions. The plans are designed to address those health needs with special providers and drug formularies that are most suitable for people with those conditions. Most SNP plans are an HMO format.
Medical Savings Account Plans (MSAs) offer a health savings account alongside the insurance benefits. Medicare itself will put a set amount of funds into your account each year. You may spend those dollars whenever you access qualifying health services. MSA plans are not available in all counties.
All Medicare Advantage plans offer their own summary of benefits, and these benefits as well as the plan’s formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year.
You can join a Medicare Advantage plan during your 7 month Initial Election Period for Medicare. You can also join or dis-enroll from Medicare Advantage during the Annual Election Period. This occurs in the fall from October 15th – December 7th.
A variety of Special Election Periods exist too. If you qualify, you might be able to join mid-year. A common one is when you move out of state and lose your existing Medicare Advantage plan. Medicare allows you a 63-day window to choose another in your new state. Another SEP occurs if you become eligible for Medicaid or the Part D Extra Help program. People with low incomes have continuous special election periods. This means you can change plans any time of year.
Medicare Advantage programs have service areas. You must be enrolled in both Medicare Parts A and B and live in the plans’ service area. You cannot join a plan that does not operate in the county where you live. A licensed health insurance agent can help you determine which plan options exist in your county. He or she will help you work through a checklist of items to see which plan best suits you.
Each year, plans set the amounts they charge for premiums, deductibles, and services. The plan (rather than Medicare) decides how much you pay for the covered services you get. What you pay the plan may change only once a year, on January 1.
If you're in a Medicare plan, review these notices your plan sends you each fall:
If you don't get these important documents, contact your plan.