Medicare Part C
Medicare Part C is most commonly known as Medicare Advantage (MA). Medicare Advantage must provide the same benefits as Part A and Part B, except for hospice care, and some services covered by Part A. If you join a Medicare Advantage plan you no longer have access to your original Medicare cost-sharing under Parts A and B and are now subject to the cost-sharing associated with the Medicare Advantage plan. Many Medicare Advantage plans include Part D: prescription drug coverage. These plans include doctor visits, hospital stays, and other health care providers within a defined network with the plans co-payments and deductibles.
Medicare Advantage Options
HMO
HEALTH MAINTENANCE ORGANIZATION (HMO)
Most HMO plans required to get medical care from healthcare providers that have contracted with the defined network for that health insurance company and plan. You have access to Emergency Room coverage throughout the United States if they are contracted with your plan or not.
In most cases, you are required to receive approval or a referral from your assigned Primary Care Provider (PCP) in order to see a specialist in the defined network.
Pro Tip: You technically have the ability to go to any healthcare provider in the defined network but your PCP isn’t required to refer you to the doctors of your choice.
PPO
PREFERRED PROVIDER ORGANIZATION (PPO)
Like HMO Medicare Advantage plans PPO plans also have a defined healthcare provider network but with a PPO you do have the option to see providers outside the defined network.
Most PPO plans don’t require a referral to see specialists but you may be required to get approvals from the plan for some services.
PPO plans reward you for staying in the defined network of healthcare providers by offering low co-payments and cost-sharing.
PFFS
PRIVATE FEE-FOR-SERVICE (PFFS)
PFFS plans aren’t the same as Original Medicare or Medigap plans.
In some cases, PFFS plans have a defined network but you can choose to go to healthcare providers outside the network. You have the ability to go to any Medicare doctor that chooses to accept the PFFS plan’s terms of service.
For each healthcare service, you receive it is important to receive approval from the healthcare provider they are willing to accept the plans payment terms.
Important
- Medicare Advantage plans are not the same as Original Medicare or a Medigap policy.
- Healthcare providers can leave a Medicare Advantage plan defined network at any time and you may lose your access to that provider.
- Medicare Advantage plans can change their benefits each year so it is important to review your plan each Annual Enrollment Period.
- You must continue to pay your Medicare Part B premium when you are enrolled in a Medicare Advantage Plan.
- You are locked into the Medicare Advantage plan the entire calendar year unless you qualify for a Special Election Period (SEP) defined by Medicare.
Medicare Open Enrollment
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We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1–800 MEDICARE to get information on all of your options.
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Last updated: 01.05.2023 at 12:01 AM MULTIPLAN_SHDLEAWE002_M