A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.

If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).

Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for non‑emergency or non-urgent care). These rules can change each year.

Health Maintenance Organization (HMO) Plans

In HMO Plans, you generally must get your care and services from providers in the plan's network, except:

• Emergency care
• Out-of-area urgent care
• Out-of-area dialysis 

In some plans, you may be able to go out-of-network for certain services. But, it usually costs less if you get your care from a network provider. This is called an HMO with a point-of-service (POS) option.

Preferred Provider Organization (PPO) Plans

In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. PPO Plans have network doctors, other health care providers, and hospitals.

Each plan gives you choice to go to doctors, specialists, or hospitals that aren't on the plan's list, but it will usually cost less if you get your care from a network provider

Private Fee-for-Service (PFFS) Plans

In some cases, you get your health care from any doctor, other health care provider, or hospital in PFFS Plans.

If you join a PFFS Plan that has a network, you can also see any of the network providers who have agreed to always treat plan members. You can also choose an out-of-network doctor, hospital, or other provider, who accepts the plan's terms, but your costs will usually be lower if you stay in the network.

Special Needs Plans (SNP)

Generally, you must get your care and services from doctors or hospitals in the Medicare SNP network, except:

• Emergency or urgent care, like care you get for a sudden illness or injury that needs medical care right away
• If you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis

Medicare SNPs typically have specialists in the diseases or conditions that affect their members.

Do I need to choose a primary doctor in Health Maintenance Organization (HMO) Plans?

In most cases, yes, you need to choose a primary care doctor in HMO Plans.

Do I need to choose a primary doctor in Preferred Provider Organization (PPO) Plans?

You don't need to choose a primary care doctor in PPO Plans.

Do I need to choose a primary doctor in Private Fee-for-Service (PFFS) Plans?

You don't need to choose a primary care doctor in PFFS Plans. 

Do I need to choose a primary doctor in Special Needs Plans (SNPs)?

In most cases, SNPs may require you to have a primary care doctor. Or, the plan may require you to have a care coordinator to help with your health care.

Health Maintenance Organization (HMO) Plans

In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don't require a referral.

Preferred Provider Organization (PPO) Plans

In most cases, you don't have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.

Private Fee-for-Service (PFFS) Plans

You don't have to get a referral to see a specialist in PFFS Plans.   

Special Needs Plans (SNPs)

In most cases, you have to get a referral to see a specialist in SNPs. Certain services don't require a referral, like these:

• Yearly screening mammograms
• An in-network pap test and pelvic exam (covered at least every other year)

Health Maintenance Organization (HMO) Plans

Are prescription drugs covered in Health Maintenance Organization (HMO) Plans?

In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want Medicare Drug Coverage (Part D), you must join an HMO Plan that offers prescription drug coverage.

Preferred Provider Organization (PPO) Plans

Are prescription drugs covered in Preferred Provider Organization (PPO) Plans? 

In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn't offer prescription drug coverage, you can't join a Medicare Drug Plan (Part D).

Private Fee-for-Service (PFFS) Plans

Are Prescription drugs covered in Private Fee-for-Service (PFFS) Plans?

Prescription drugs may be covered in PFFS Plans. If your PFFS Plan doesn't offer drug coverage, you can join a Medicare Prescription Drug Plan to get coverage.

Special Needs Plans (SNPs)

Are prescription drugs covered in Special Needs Plans (SNP)?

All SNPs must provide Medicare prescription drug coverage.

1. You're still in the Medicare Program.

2. You still have Medicare rights and protections.

3. You still get complete Part A and Part B coverage through the plan. Plans may offer some extra benefits that Original Medicare doesn’t cover – like vision, hearing, and dental services.

4. Your out-of-pocket costs may be lower in a Medicare Advantage Plan. If so, this option may be more cost effective for you. Note: You may be charged copayments during the first 20 days.

5. You can’t buy and don’t need Medigap.

6. You can only join a plan at certain times during the year. In most cases, you're enrolled in a plan for a year.

7. You can join a Medicare Advantage Plan even if you have a pre-existing condition

8. You can check with the plan before you get a service to find out if it's covered and what your costs may be.

9. Following plan rules, like getting a Referral to see a specialist in the plan's Network can keep your costs lower. Check with the plan.

10. Go to a doctor, other health care provider, facility, or supplier that belongs to the plan's network, so your services are covered and your costs are less. In most cases, this applies to Medicare Advantage HMOs and PPOs.

11. Providers can join or leave a plan’s provider network anytime during the year. Your plan can also change the providers in the network anytime during the year. If this happens, you may need to choose a new provider.

12. If you join a clinical research study, some costs may be covered by your plan. Call your plan for more information. Get your plan's contact information.

13. Medicare Advantage Plans can't charge more than Original Medicare for certain services like chemotherapy, dialysis, and skilled nursing facility care.

14. Medicare Advantage Plans have a yearly limit on your out-of-pocket costs for medical services. Once you reach this limit, you’ll pay nothing for covered services. Each plan can have a different limit, and the limit can change each year. You should consider this when choosing a plan.

15. If the plan decides to stop participating in Medicare, you'll have to join anothe rMedicare Health Plan or return to Original Medicare.

16. You can only be in one Medicare Advantage Plan at a time.