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Quick Medicare Advantage refresher
What is Medicare Advantage?
- It’s another name for Medicare Part C
It is offered by private health insurance companies
Plans can have $0 premiums
Plus, extra benefits that Original Medicare doesn’t cover
The Medicare Advantage dictionary
Coinsurance
The percentage you pay of the total cost of certain medical services.
Copayment (Copay)
A fixed amount you pay each time you receive certain medical services.
Deductible
The amount you must pay for medical services. This is before the plan begins to pay its share.
Health maintenance organization (HMO)
It is a health insurance plan. It has a network of doctors, health providers, and hospitals.
In-network provider
A health provider who has a contract with a plan to provide health services to its plan members.
Maximum out-of-pocket (MOOP)
The most you pay out-of-pocket during the calendar year for covered services.
Provider network
Doctors, health providers, and hospitals that a plan contracts with to provide medical care to its members.
Out-of-network
A health provider who does not have a contract with a plan to provide medical services to its plan members.
Preferred provider organization (PPO)
It’s like an HMO. But it offers an out-of-network benefit. You’ll usually pay more for out-of-network benefits.
Premium
The recurring payment to Medicare or a health plan for health and/or prescription drug coverage.
Prior authorization
Approval in advance from a health plan to get certain services or certain drugs.
Private fee-for-service (PFFS)
It’s a like a PPO. The difference is you can go to any provider that accepts the plan’s payment.
Referral
A written order from your primary care provider. It’s for you to see a specialist for a specific medical service.
Which plan should I choose?
Below we compare common kinds of Medicare Advantage plans. Download this chart as a PDF. You can also print it to keep it handy.
| HMO | PPO | PFFS | |
|---|---|---|---|
| Does this kind of plan have a provider? | Yes | Yes | Yes |
| Does this kind of plan have in-network benefits? | Yes | Yes | Yes |
| Does this kind of plan have out-of-network benefits? | No(only in very limited situations, like for emergency or urgent care) | Yes(out-of-network benefits will usually cost you more than in-network benefits) | Yes(out-of-network benefits will usually cost you more than in-network benefits) |
| Do I need to pick a primary care provider (PCP)? | Yes(if you don't choose one, the plan may pick one for you) | No(but it’s a good idea to choose one) | No(but it’s a good idea to choose one) |
| Can I change my PCP at any time? | Yes | Yes | Yes |
| Does my PCP or specialist have to get approval in advance from the plan for me to get certain services? | This requirement may be different between plans - check the plan's documents | This requirement may be different between plans - check the plan's documents | No(but it’s a good idea to choose one) |
| If a plan has out-of-network services, do I have to get prior authorization? | This kind of plan does not have an out-of-network benefit | No | No |
| Do I have to get a referral from my PCP to see a network specialist? | This requirement may be different between plans – check the plan’s documents | This requirement may be different between plans - check the plan's documents | No |
| Do I have to get a referral from my PCP to see an out-of-network specialist? | This kind of plan does not have an out-of-network benefit | No | No |
| Which plan gives me the most freedom when getting care from a provider? | YesChoose from in-network providers for most care | YesIn-network providers and out-of-network providers who accept Medicare | YesIn-network providers and out-of-network providers who accept the plan’s payment |
| Does this kind of plan have a monthly premium? | This may be different by plan – check the plan’s documents | This may be different by plan – check the plan’s documents | Most PFFS plans will have one |
| Does this kind of plan have a maximum out-of-pocket amount? (This is the most you will pay for covered services during the year. If you reach this amount during the year, the plan will pay 100% for your care for the rest of the year.) | Yes | Yes(this amount is generally higher than on an HMO) | Yes(this amount is generally higher than on an HMO) |
| Does this kind of plan have a deductible for medical services?(I have to pay the full cost up to this amount. After that, the plan’s copays will kick in.) | This may be different between plans – check the plan’s documents | This may be different between plans – check the plan’s documents | This may be different between plans – check the plan’s documents |
| Does this kind of plan have predictable copays? | Yes | Yes(usually for in-network services) | Yes(usually for in-network services) |
| Does this type of plan offer extra benefits? Things like dental cleanings and fillings, eyeglasses, hearing aids, etc.? | Yes | Yes | Yes |
| Does this kind of play offer prescription drug benefits? | Depends on the plan you choose | Depends on the plan you choose | Depends on the plan you choose |
We hope this helps.
We hope you found this information useful. If you still have questions, give us a call. If a family member is helping you make decisions, have her or him call us. We want to make sure you get answers to your questions.
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