The Different Types of Advantage Plans

When it comes to Medicare Advantage plans, you have options. There are many consistencies you can expect with most HMO, PPO and PFFS plans, and there are some differences to note to help you consider your best options.

A good rule of thumb to consider- typically the more freedom you have, the more risk of additional costs you’re open to. Some plans will include prescription drugs, and some will not. Many also require care of a primary care Physician.

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HMO (Health Maintenance Organization)

An HMO, or Health Maintenance Organization, is designed to keep costs low and predictable. With one doctor to coordinate your care, an HMO health plan is easy to use and may be just what you’re looking for.

  • Monthly premiums, copays and deductibles are often lower with lower Maximum-Out-of-Pocket Costs than other types of plans.
  • Emergency and urgent care are out of network services.
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PPO (Preferred Provider Organization)

A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PPO Plans have network doctors, other health care providers, and hospitals. You pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network.

  • Higher costs for out-of-network solutions
  • You can go outside the network of doctors to receive care, but ultimately it is up to the out of Network doctor to accept the insurance.
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PFFS (Private Fee-for-Service)

A Medicare PFFS Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PFFS plans aren’t the same as Original Medicare or Medigap. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.

  • These plans typically don’t require a referral.
  • PFFS a fee assignment type of plan, they cover out of network at a higher rate than in network similar to PPOs. However, PFFS can require advanced negotiation from the insurance company and the care provider to allow treatment.

Are prescription drugs covered in HMO, PPO or PFFS Plans?  Most plans include prescription drug coverage, but some do not. It’s best to consult with an Agent to compare plans with personal needs.

Do I need a Primary Care Physician?  Most plans will require you to select a primary care doctor. Most HMOs will require you to go to this doctor to get a referral in order to see a specialist. PPOs and PFFS usually do not require a referral to see a specialist from your primary care doctor.

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