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Benefits & Coverage

The Five Types of Medicare Advantage Plans

A woman talks to a broker about the five types of Medicare Advantage plans.

With the Annual Enrollment Periodright around the corner, it’s time to start deciding whether you want to stick with Original Medicare, opt in to Medicare Advantage (Part C) or switch to a new Medicare Advantage Plan. How do you distinguish between different plans in your area to decide what’s best for you?

When it comes to Medicare, there are more options than you may expect, but that doesn’t mean they are simple to wade through. Our guide will prepare you with the tools you need to determine the right plan for you or your loved ones.

Two Main Types of Medicare Advantage Plans

Medicare Advantage (Part C) is an optional plan that extends your coverage from what you’d get through Original Medicare (Parts A and B). With Medicare Advantage, you’ll generally have preventive care benefits like dental, vision and mental health coverage, and even benefits for wellness and fitness programs. While Original Medicare doesn’t come with prescription drug coverage (Part D) and requires you to purchase a stand-alone plan, most Medicare Advantage plans come with Medicare Part D.  The biggest advantage of a Medicare Advantage plan is the maximum out-of-pocket limit. This is an annual cap on out-of-pocket costs. The limit is high, but it can protect you from high-cost care and treatments.

In addition to their added benefits, Medicare Advantage plans are usually bookended by their type, which distinguishes how you generally receive and pay for your care.

HMO (Health Maintenance Organization)

An HMO is a cost-effective plan but has restrictions based on the plan’s network of doctors and hospitals. The only times you don’t need to see an in-network doctor or hospital is for:

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

If you need to see an out-of-network provider, then your best option will be to sign up for an HMO-POS (Health Maintenance Organization Point-of-Service) plan, like Baylor Scott & White Health Plan’s version. These plans are just like a normal HMO; however, they allow you to get some services out-of-network for a higher copayment or qualifying deductible.

PPO (Preferred Provider Organization) 

A PPO has a specific network of doctors and hospitals that it covers. Some of these care providers will be more “preferred” by your plan than others within network, which means you’ll save money when seeing them compared to other in-network physicians. With a PPO, you pay less when going to in-network doctors and facilities; but, like an HMO-POS, you can still see out-of-network providers for covered services, and you may pay more. However, physicians are not required to see you when out of network. Our BSW SeniorCare Advantage PPO plans cover care in Central, West and North Texas.

Other Medicare Advantage Options

HMOs and PPOs offer a range of options for care with reliable in-network providers. However, if the options in your area don’t suit your individual needs or if you have special needs that require a more personalized plan, there are other Medicare Advantage options available.

  • PFFS (Private Fee-for-Service): These plans determine how much you pay for services differently from other Medicare plans. Even doctors who accept Medicare may not accept your PFFS plan’s pricing. When you see a physician, you cannot present your red, white and blue Medicare card, because Original Medicare will not cover your healthcare while on a PFFS plan.
  • MSA (Medicare Medical Savings Accounts): This is a consumer-directed Medicare Advantage Plan, most similar to a Health Savings Account (HSA) that you may be familiar with from your employer group or marketplace plan. MSAs have two parts—a high-deductible plan and a Medical Savings Account (MSA). These plans typically don’t have a network of doctors, allowing you to choose your providers. However, they also tend to have high deductibles, which means you spend more money out-of-pocket when seeing doctors.
  • SNP (Special Needs Plans): There are several types of plans within the SNP umbrella; however, in a nutshell, they provide benefits for individuals with specific and severe chronic diseases, unique healthcare needs or who also have Medicaid. SNPs tailor their benefits via a care coordinator. They will be either an HMO or PPO type and will cover the same as Medicare Parts A and B, like all Medicare Advantage Plans. However, an SNP may also cover extra services for the special groups it serves.

Before enrolling in a Medicare Advantage plan, ensure that the program you’re looking at offers your medications in a formulary and covers your preferred physicians. Baylor Scott & White Health Plan offers an HMO-POS plan, a PPO plan and a new HMO plan. When choosing a coverage plan, there is a lot to consider. Contact a Baylor Scott & White licensed insurance agent for a consultation on your options and guidance on finding a plan that’s best for you or your loved ones at 1.833.975.0841 (TTY: 711). Para hablar con un representante en español, llame a 1.833.412.3320.