Beneficiaries have several types of Medicare Advantage plans to choose from. All Advantage Plans must follow Medicare rules and cover all Medicare Part A and B services. How the plans pay benefits for those services depends on the plan. These plans may or may not also include a Part D prescription drug component. Medicare Advantage Plans are based on geographic locations and all plans are not available in all Wisconsin counties.
Types of Medicare Advantage Plans
Health Maintenance Organizations (HMO) – beneficiaries generally must get care and services from providers (doctors, specialists, hospitals) in the plan’s strictly defined network (except emergency care, out-of-area urgent care, or out-of-area dialysis), and they may need a referral from the primary care doctor to see a specialist.
Point of Service (HMO-POS) – this option is available with some HMO plans which allows the beneficiary to go out-of-network for certain services, but the out-of-pocket costs may be higher.
Preferred Provider Organizations (PPO) – local and regional – PPO’s have a defined network of providers, but beneficiaries can use out-of-network providers (if those providers will accept the plan), usually with higher associated out-of-pocket costs.
Private Fee-for-Service Plans (PFFS) – beneficiaries can go to any Medicare-approved provider that accepts the plan’s payment terms and agrees to treat them. Not all providers will. [If a beneficiary joins a PFFS Plan that has a network, they can also see any of the network providers who’ve agreed to always treat plan members. They can choose an out of network doctor, hospital, or other provider who accepts the plan’s terms, but may pay more.] If the plan does not offer drug coverage, can have a separate Medicare Part D drug plan.
Special Needs Plans (SNP) – beneficiaries generally must get care and services from providers in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis); may need a referral from the primary care doctor to see a specialist. All SNP’s must provide Medicare Part D prescription drug coverage.
SNPs provide focused and specialized health care for specific groups of beneficiaries and therefore limit plan membership to people in one of the following groups:
- Institutional SNP (I-SNP): Those living in certain institutions (like a nursing home), or who require nursing facility-level of care at home.
- Dual Eligible SNP (D-SNP): Those eligible for both Medicare and Medicaid.
- Chronic Condition SNP (C-SNP): Those with specific chronic or disabling conditions (e.g. cancer, diabetes, cardiovascular disorders).
Medicare Medical Savings Account Plans (MSA) – combines a high-deductible Medicare Advantage health plan with a special savings account in which Medicare deposits money (generally at the beginning of each year) for the beneficiary to use to pay for health care services. Only the plan can make deposits into the MSA account; plan enrollees cannot deposit their own money. The amount of deposit can change each year and may also earn interest. Any money left in the account at the end of the year will remain in the account and will be added to the new deposit the following year if the enrollee choses to continue enrollment. An MSA plan must, after the enrollee has met the plan deductible, cover in full all original Medicare Part A and B services for the remainder of the year. These plans do not offer a Part D Prescription Drug benefit. Beneficiaries are not eligible to enroll in this plan if enrolled in a Federal Employee Health Benefits program, eligible for VA benefits, or are dual eligible (Medicare/Medicaid).
Medicare.Gov
Wisconsin OCI Guide to Medicare Advantage
Understanding Medicare Advantage - CMS
