What is Medicare?
Medicare is a federal health insurance program for U.S. adults age 65 or older and younger people who receive disability benefits.
There are 2 main ways to get your Medicare coverage:
Includes Medicare Part A & Medicare Part B, with options to add on additional coverage
Medicare Advantage Plans
These plans combine Medicare Part A, Medicare Part B, and usually Medicare Part D (Prescription Drug Plans)
Medicare Part A (Hospital Insurance)
Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
Medicare Part B (Medical Insurance)
Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.
A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all 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, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage. More information on Medicare Advantage Plans can be found at the bottom of this page.
Additional Medicare Plans
Additional coverage for prescription drugs and/or Medicare Supplement Insurance
Part D adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.
Sold by private companies, can help pay some of the health care costs that Original Medicare doesn't cover, like co-payments, coinsurance, and deductibles. Some Medigap policies also offer coverage for services that Original Medicare doesn't cover, like medical care when you travel outside the U.S. If you have Original Medicare and you buy a Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs. Then your Medigap policy pays its share. A Medigap policy is different from a Medicare Advantage Plan. Those plans are ways to get Medicare benefits, while a Medigap policy only supplements your Original Medicare benefits.Medigap plans are available State Wide. If you move out of State, generally you can take it with you.
Medicare Advantage Plans
There are 3 main types of Medicare Advantage plans. They are also called Medicare Health Plans or Part C Plans.
1.) PFFS otherwise known as Private Fee For Service plans. Generally no networks. These plans are similar to Medicare A and Medicare B except the doctor has to DEEM the plan. That means that even though the doctor is a Medicare doctor, they can accept or reject the plans terms of agreement on a per visit basis. Also the PFFS may be a Medicare Advantage only plan without prescription drugs included. If that is the case, the consumer may select any PDP to go along with the PFFS just like original Medicare A & B. The PFFS does not require referrals to specialists and no PCP (Primary Care) is selected.
2. PPO otherwise known as Preferred Provider Network. The name gives it away. They PREFER you go to in network providers however they cannot require you to do that. You may pay higher out of network co-pays and co-insurances, however you can go. The PPO requires a PCP, however you do not have to use that PCP and can receive care from anyone who accepts the terms of coverage. ANY doctor may obtain PA (Prior Authorization) for a test or procedure. PPO plans can also be LPPO (Local Preferred Provider Network) or RPPO (Regional Preferred Provider Network).
3. HMO otherwise known as Health Maintenance Organization. These are the most restrictive as far as the ability to choose providers. The HMO plans generally require referrals and rarely refer out of network. They are available in HMO POS. POS otherwise known as Point Of Service. This allows those in the Network to venture outside the network for care. It should be taken lightly and used rarely. The contracts state that it covers certain items under certain conditions. A variation of the HMO is the HMO DSNP for specialized beneficiaries. These plans are for those with Medicare and Medicaid. Another variation is the CSNP for those with specific chronic illnesses.
All Medicare Advantage plans are guarantee issue for the stated purpose and specific to service areas. They also have specific enrollment periods available to enroll and/or dis-enroll. If you have a Medicare Advantage where you live, your neighbor may not have it available to them. It could be that they do not qualify for a DSNP because of income or they live in the next county over from you and the plan you have is not offered in that county.