Medicare can be confusing. You have hospital coverage through Part A, medical coverage through Part B, and there’s also Medicare Advantage options to consider. But, do you really need an Advantage plan? Read this before you sign.
Health Maintenance Organization Plans
If you have an HMO, you can usually only use doctors, hospitals or other health care providers on the plan’s list, and you may have to get a referral from your primary care doctor to be seen. Most HMOs will include prescription drug coverage.
There are exceptions to this, including:
- Emergency care
- Out-of-area urgent care
- Out-of-area dialysis
Preferred Provider Organization Plans
Also known as PPOs, these plans allow you to use providers who aren’t in your plan’s network, though you will have to pay a higher cost.
Most of the time, prescription drugs will be covered.
Unlike an HMO, a PPO doesn’t require you to choose a primary care physician and you don’t have to have a referral to see specialists.
Private Fee-for-Service Plans
A PFFS sets a certain amount that they will pay for doctors, health care providers and hospitals.
Your ability to see any providers you want will depend on the plan you choose.
Some will allow you to see anyone, while others will restrict you to a certain network, though you can still see an out-of-network doctor at a higher cost.
Prescription coverage will also depend on the plan you choose. There are some PFFS plans that include prescriptions. If you choose one that doesn’t, you can join a Medicare Prescription Drug Plan.
You don’t need to choose a primary care physician or get a referral to see specialists when necessary.
Special Needs Plans
Special Needs Plans cover those who have certain diseases or issues. This type of plan is characterized by tailored benefits, providers and drugs that meet the needs of the group they serve.
Your care would need to come from certain doctors or hospitals, unless you’re in an emergency or urgent situation or you need out-of-area dialysis for end-stage renal disease.
These plans are required to provide prescription drug coverage, you must choose a primary care physician and you have to get a referral to see a specialist.
$0 Premium Plans
Plans with no premium are available when Medicare Advantage partners with the Centers for Medicare and Medicaid Services.
The federal government pays a flat rate to the insurance company to fund the costs of your coverage. This amount is determined by your age, sex and health status.
A $0 premium plan may still require that you pay copays, deductibles and coinsurance costs. There is a cap, however, on how much you would have to pay in a calendar year.
This plan involves working with a network of doctors and health care providers.
Choosing the right path
This is a lot of information to digest. Your best bet is to talk with an independent insurance expert who can go over the options with you in greater detail.
Contact UROne Benefits™ today at 800-722-7331. We’ll guide you toward the plan that best fits your particular needs.
This post was originally published in January 2018; updated February 2024.