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Medicare Advantage Plan Types

There are several types of Medicare Advantage Plans, not every plan type will be available in your area. Different plans are available based on the county that you reside, so it is always good to ensure that you know what each plan type is, the benefits and to ensure that the plan you have is the most beneficial for you.

HMO

Health Maintenance Organization. A Health Maintenance Organization requires you to use 'in-network' providers unless it is an emergency situation. Each carrier will have their own network of providers, so when choosing your plan you should always ensure that your doctors are in the network. Typically, you can only access non-emergency or general care in your plans service area which may be limited to specific counties within your state. You will pay 100% Out of Pocket if you use any doctors not in your plans network.

PPO

Preferred Provider Organization. A Preferred Provider Organization allows you to see providers in and out of the network. The providers that are 'in-network' will be less expensive to use and will typically have a flat copay. 'Out of Network' providers are typically billed on a coinsurance basis and can be 40-50% coinsurance. Preferred Provider Organizations may also have a larger service area and allow 'in-network' care in other states.

HMO POS

Health Maintenance Organization Point of Service. A Health Maintenance Organization Point of Service allows you to see some doctors that are 'Out of Network' for a higher fee than if an 'in-network' provider had seen you instead. Unlike, the Health Maintenance Organization plans, the Health Maintenance Organization Point of Service will allow you to see the 'Out of Network' providers without having to pay 100% Out of Pocket.

PFFS

Private Fee For Service. A Private Fee For Service allows you to see any provider that agrees to accept the plans terms and conditions. This requires you to call the doctors office before services are provided to ensure coverage is still available. This must be done EVERY time before an appointment. Private Fee For Service plans allow you the freedom to see any doctor willing to accept the terms, but may also be disruptive if the doctor decides to stop accepting the plan.

DSNP

Dual-Eligible Special Needs Plan. A Dual-Eligible Special Needs Plan is for those that are on both Medicare and Medicaid. Dual-Eligible Special Needs Plans combine the federal Medicare benefits with the State Medicaid benefits, leaving the beneficiary with very little Out of Pocket health care expenses. Dual-Eligible Special Needs Plans may also offer additional benefits that are not provided by Medicare or Medicaid. These benefits will vary from each plan and Dual-Eligible Special Needs Plans are not available in all service areas.
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