Options Under Medicare Advantage

Medicare Advantage Plans are health plan options (like HMOs and PPPs) approved by Medicare and run by private companies. These plans are part of the Medicare Program and are sometimes called "Part C" or "MA plans." Medicare pays an amount for your care every month to these private health plans. Medicare Advantage Plans must follow rules set by Medicare. Medicare Advantage Plans aren't supplemental insurance.

Insurance companies offering Medicare Advantage health plans in Wisconsin must be licensed before Medicare will enter into an arrangement to purchase coverage for you. Medicare Advantage plans are based on your geographic location and are not available in all Wisconsin counties. The types of Medicare Advantage plans available in Wisconsin are:

  • Health Maintenance Organization (HMO): A type of managed care health plan with a defined list of providers, often referred to as a network, that enrollees must use. HMOs generally have more restrictions on the providers you may use than other types of health plans in which you can enroll, although they often provide benefits, such as additional preventive care, that are not available from other types of health plans. Normally, an HMO will make referrals to non-network providers only in unusual situations. The HMO may also require that you obtain a referral from your primary provider before seeing a specialist. Other than in an emergency situation, an HMO will not pay for services you obtain from a provider who is not part of the HMO's network. Before you enroll in an HMO, you should carefully review the list of providers that is available through the HMO. You should also review whether the HMO allows access to out-of-state provider networks. HMOs do not cover services provided by non-network providers that are not emergency or urgent care situations. Typically, an HMO has only small copayments for covered medical services.
  • Point of Service Plan (POS): A type of managed care health plan with a network of providers that also permits you to use non-network providers, usually at some additional cost to you. The POS plan may also have requirements that you obtain a referral from your primary provider before the plan will agree to pay for out-of-network care. Similar to the HMO, the POS has small copayments for medical services received from providers in the network.
  • Preferred Provider Plan (PPP): A type of managed care health plan offered by private health insurance companies that pays a specific level of benefits if certain providers are used, and a lesser amount if non-PPP providers are utilized. Like an HMO, a PPP operates in a certain geographic area and is limited to specific providers.
  • Private Fee for Service (PFFS): A type of health plan offered by private health insurance companies. The plan allows you to go to any Medicare-approved provider, such as a doctor or a hospital, who before treating you agrees to accept the Medicare PFFS plan's terms and conditions of payment. The provider can decide at every visit whether or not to accept the plan and agree to treat you. Some providers who accept original Medicare may not accept PFFS plan enrollees.

    If you see a provider who does not accept Medicare assignment, you may be responsible for any charges that are up to 15 percent in excess of the Medicare-allowed amount. If you see a provider who does not participate in the Medicare program, you will not be covered and will be responsible for the entire amount charged by the provider. The plan may charge you, through premiums, additional out-of-pocket expenses (such as copayments and coinsurance), or both for any costs that exceed what original Medicare would pay.

    PFFS plans are not required to coordinate care, establish provider networks, or adopt utilization management strategies.

Other Medicare Advantage options you may hear about are:

  • Medicare Medical Savings Account (MSA): A health plan option made up of two parts. One part is a high deductible health insurance policy that covers the same services as Medicare Part A and Part B. The other part is a special savings account where Medicare deposits money to help you pay for expenses to meet the deductible. The deductible may be as high as $6,000 annually.
  • Medicare Special Needs Plan (SNP): A special type of health plan limited to people in certain institutions (such as nursing homes), or eligible for both Medicare and Medicaid, or with certain chronic or disabling conditions. SNPs are available in limited areas, and are designed to provide services to people who can benefit the most from special experts of plan providers and from care management.

Remember, you do not have to leave original Medicare unless you choose to. The cheapest policy may not be the best option for you. Some things you may want to consider if you decide to choose a Medicare Advantage plan include:

  1. What providers are available to you?
  2. Will the plan allow you to see the providers you want?
  3. Are there any additional benefits that may be offered, and is there an additional charge for these benefits?
  4. What are the benefits that are excluded but would be covered under an original Medicare supplement policy?
  5. What is the total cost to you, including premiums, coinsurance, copayments, deductibles, or other out-of-pocket expenses?
  6. How often and by how much can the plan raise your premiums?
  7. If you have a specific health condition, is one type of plan better suited to provide the services you need?
  8. Will the plan coordinate with my current employer-sponsored or union plan? Generally, plans that offer you more freedom in choosing providers or that cover additional benefits will cost you more, either in premiums or out-of-pocket expenses.