How Do Medicare Advantage Plans Work?

Can I get my health care from any doctor or hospital?

Private Fee for Service (PFFS) Plan : In some cases, yes. You can go to any Medicare-approved doctor or hospital that accepts the plan’s payment terms and agrees to treat you. Not all providers will. If you join a PFFS Plan that has a network, you will usually pay more to see out-of-network providers.

Medical Saving Account (MSA) Plan : Yes. Some plans may have preferred doctors and hospitals you could go to for a lower cost.

Special Needs Plan (SNP) : You generally must get your care and services from doctors or hospitals in the plan’s  network (except emergency care, out-of-area urgent care, or out-of-area dialysis). Plans typically have specialists for the diseases or conditions that affect their members.



Are prescription drugs covered?

PFFS Plan : Sometimes. If your PFFS Plan doesn’t offer drug coverage, you can join a Medicare Prescription Drug Plan to get coverage.

MSA Plan : No. You can join a Medicare Prescription Drug Plan to get drug coverage.


SNP Plan : Yes. All SNPs must provide Medicare prescription drug coverage (Part D).



Do I need to choose a primary care doctor?

PFFS Plan : No.

MSA Plan : No.






SNP Plan : Generally, yes, or you may need to have a care coordinator to help plan your care.





Do I have to get a referral to see a specialist?

PFFS Plan : No.
MSA Plan : No.
SNP Plan : In most cases, yes. Yearly screening mammograms and an in-network Pap test and pelvic exam (at least every other year) don’t require a referral.


What else do I need to know about this type of plan?

PFFS Plan :

■ PFFS Plans aren’t the same as Original Medicare or Medigap.
■ The plan decides how much you must pay for services.
■ Doctors, hospitals, and other providers may decide on a case-by-case basis not to treat you even if you’ve seen them before.
■ For each service you get, check to make sure your doctors, hospitals, and other providers will agree to treat you under the plan, and that they will accept the PFFS Plan’s payment terms.
■ In an emergency, doctors, hospitals, and other providers must agree to treat you.


MSA Plan :

■ Medicare MSA Plans have two parts: a high deductible health plan and a bank account. Medicare gives the
plan an amount each year for your health care, and the plan deposits a portion of this money into your account. The amount deposited is less than your deductible amount, so you will have to pay out-of-pocket before your coverage begins.
■ Money spent for Medicare-covered Part A and Part B services counts toward your plan’s deductible. After you reach your out-of-pocket limit, your plan will cover your Medicare-covered services in full.
■ Any money left in your account at the end of the year remains in your account along with the deposit for
next year.




SNP Plan :

■ A plan must limit plan membership to people in one of the following groups:
1) people who live in certain institutions (like a nursing home) or who require nursing care at home, or
2) people who are eligible for both Medicare and Medicaid, or
3) people who have one or more specific chronic or disabling conditions (like diabetes, congestive heart failure, a mental health condition, or HIV/AIDS).
■ Plans may further limit membership within these groups.
■ Plans should coordinate the services and providers you need to help you stay healthy and follow your doctor’s orders.
■ If you have Medicare and Medicaid, your plan should make sure that all of the plan doctors or other health care providers you use accept Medicaid.
■ If you live in an institution, make sure that plan doctors or other health care providers serve people where you live.