Medicare Advantage Plans

What Are Medicare Advantage Plans?

A Medicare Advantage plan is a private health insurance plan that is Medicare-approved.  Medicare Advantage plans are either PFFS plans, PPO plans, HMO plans, or Special needs plans.  Sometimes referred to as an “all-in-one” alternative to standard Medicare, this plan may cover your Part A (hospital insurance), B (medical insurance), and D (drug coverage) benefits. Many plans may also offer additional benefits, such as vision, dental, hearing, and even gym memberships. 

When choosing a Medicare Advantage plan, you may also opt to receive coverage for more services, such as over-the-counter drugs or transportation to doctor visits. Plans can be customized for condition-specific treatments with benefits pertaining to chronically ill recipients. 

Is Medicare Advantage being cut?

The funding for Medicare Advantage (MA) plans, which are private health insurance plans that are an alternative to traditional Medicare, is not currently being cut. However, changes to funding for MA plans have been proposed in the past, and could be proposed again in the future.

It’s worth noting that funding for Medicare Advantage plans comes from the federal government, and can be subject to changes in legislation and government budget priorities. Any changes to MA plan funding would need to be approved by Congress and signed into law by the President, so it’s important to stay informed about proposed changes and how they may impact your healthcare coverage.

If you are enrolled in a Medicare Advantage plan, it’s a good idea to stay in touch with your plan provider and keep up to date on any changes to your coverage or benefits. You can also contact the Centers for Medicare and Medicaid Services (CMS) for more information about changes to MA plans and other aspects of Medicare.

Rules for Medicare Advantage Plans

Medicare Advantage plans work by directing your Medicare to pay a set monthly amount for your care. As a result, you will receive coverage for all of your Part A and Part B services, as well as additional benefits if offered in your plan. 

Rules may apply to how you can receive services, such as:

  • Possibility of a referral to a specialist (HMO)
  • The need to receive medical care that is considered non-urgent 

In order to get a medicare advantage plan, you must also, 

  • Continue to pay for your Medicare Part B premium
  • 100% be enrolled in both Medicare Part A and Medicare part B 
  • Live in the plan’s service area

Services from providers that are outside of the plan’s network or service area may not be covered by your Medicare Advantage plan, so to ensure the lowest costs, make sure to use doctors and providers in your plan’s service area

Pros of Medicare Advantage Plans

There is a major possibility that the Medicare Advantage Plans may cost you less.  Your insurer determines the premium of your Medicare Advantage plan, and while you must still continue to pay your Part B premium, some Advantage plans may have premiums as low as $0.  In addition, your cost-sharing may be less with a Medicare Advantage plan. An Advantage plan also limits your out-of-pocket expenses, as once the maximum is reached, you won’t have to pay for medical services covered by your plan for the rest of the year. 

Medicare PPO Plans

A Medicare PPO is a plan that contains health providers who agree to see the clients of the plan at a certain rate of pay. A PPO is what is called a Preferred Provider Organization.

What exactly is a Medicare PPO?

The Medicare PPO is also a type of Medicare Advantage Plan that can be joined just like an HMO. With a PPO copays are lower as long as you see the providers within the network. Unlike HMOs, PPOs do not require you to have a primary care physician. You will also not need referrals to see a specialist, however, the plans vary and rules are different for each plan.

While under a PPO plan Medicare Parts A and B are provided to you. Not only that, there is a limit to how much you can spend out-of-pocket. Due to the fact that there is a cap in place, it will protect you from spending more than you should if medical costs are high.  For example, a decade ago any Medicare Advantage plan out in the market was only allowed to set a maximum of $7,550 out-of-pocket costs.

PPO Features

  • The choice to see doctors who are out-of-network, but it costs more
  • Low premiums since you agree to the limitations and rules set by the plan
  • A Part D drug plan is usually added along with the plan although, it has to be one of the drug plans tied in with the PPO plan
  • Extra benefits are a possibility with PPOs however, there are limitations, possible copays, and restrictions along with the benefits

Costs with Medicare PPO Plans

  • Medicare Part B will still have to be paid for separately from the PPO costs
  • A monthly premium will be incurred with a PPO, granted some plans might have a $0 premium which has the possibility of changing every year
  • Copays will have to be paid for medical services
  • If you choose to go out-of-network be prepared to pay higher costs
  • The Part D drug plan is usually attached to the plan so most times it will not cost any additional money for that part.

Medicare HMO Plans

What makes the HMO plans so popular among U.S. citizens? The HMO plans offer low premiums which are very enticing. In fact, some of the plans that are offered even have a $0 premium. To be eligible for an HMO you have to be already enrolled in Medicare Part A and B and also paying for those parts. When it comes to treatment and where you can receive it, in-network providers will be the main source to go to aside from a medical emergency.

What is HMO Medicare?

HMO stands for a health maintenance organization in which those on Medicare can use the Medicare services tied into these organizations. The HMO plans belong to a network that manages sed plans and has select doctors and hospitals that are within it. With an HMO you will have a primary care physician that you go to for care. The insurance company that handles HMO plans will create contracts with specific physicians and doctors around the area that you reside in which will form the network you will use.

In the chance you have a health condition that the primary care physician cannot treat, they will then refer you to a specialist network. Some plans might not even need a referral to get special care.

The HMO plan does not replace Medicare Part B. Being enrolled in Medicare Part A and B is a requirement before enrolling in an HMO plan. Not only that, but the area you reside in also must be within the area the HMO plan covers.

If you decide to enroll in an HMO plan, your care then goes through the plan’s network. Emergencies however do not go through the network.

Medicare HMO Features

  • The application for a Medicare HMO no longer has health questions. In the years before 2021, any Medicare Advantage plan contained one question which was asking if the client has end-stage renal disease. Today, however, this question is now gone from any application.
  • Depending on the area you reside in, premiums might be lower than in other areas. Keep in mind that every year premiums do change so look out for an Annual Notice of Change letter that is sent out every fall.
  • There is a local network made up of healthcare providers within the area you live in that are to be seen if you need care. Most plans as stated above in a previous section will have you select a primary care physician.
  • A Part D Medicare drug plan is also usually attached to an HMO plan. Double-check the drug list to see if the medication you are currently on is covered.
  • With HMOs, you pay either coinsurance or co-pays. The co-pays depend on the service you receive, so bloodwork, doctor visits, etc. will vary on price for each one.

Medicare PFFS

A Medicare PFFS meaning is short for Private Fee for Service, which is one of the few Medicare Advantage plans available in certain areas. 

Understanding a Medicare PFFS

Understand that the Medicare PFFS plan does not work like a Medicare Supplement would, it is a Medicare Advantage plan. Before signing up for the plan know that the premiums, copays, coinsurance all incurred from medical services will be paid by you the signer. However, while that is similar to a PPO or HMO the difference is you are not limited to a network. 

This means that if you are to go to any medical care institution, you must show your Medicare PFFS plan card to the provider and they must agree to the terms and conditions of the plan, bill plan, and payment.  

Common Features

  • The PFFS card can be presented at any participating Medicare provider within the U.S. to see if the provider will then treat you. Those who travel a lot within the U.S. are likely to choose a Medicare PFFS plan because of this. 
  • PFFS plans can have a separate Part D drug plan meaning you are able to choose a drug plan with a different company while using the PFFS for covering health only.

What does pffs mean in insurance

PFFS stands for Private Fee-For-Service, which is a type of health insurance plan offered by some private insurance companies in the United States. PFFS plans allow you to see any doctor or healthcare provider who accepts the plan’s payment terms and conditions. These plans generally have a set schedule of fees for medical services and may require you to pay a certain amount out-of-pocket for each service you receive. PFFS plans may also offer additional benefits, such as prescription drug coverage and wellness programs.

What is pffs insurance

One of the key features of PFFS plans is their flexibility. Unlike other types of insurance plans, PFFS plans do not require you to choose a primary care physician or obtain referrals to see specialists. You are free to choose any doctor or healthcare provider who accepts the plan’s payment terms and conditions, regardless of whether they are in the plan’s network.

However, it’s important to note that not all healthcare providers may accept PFFS plans. Before seeking medical care, it’s important to confirm with your healthcare provider that they accept your PFFS plan.

What is a pffs insurance plan

Another important aspect of PFFS plans is their cost-sharing structure. Like other insurance plans, PFFS plans may require you to pay a portion of the cost of medical services you receive. This may include deductibles, copayments, and coinsurance. The amount you are required to pay out-of-pocket may vary depending on the plan you choose and the services you receive.

Overall, PFFS plans can offer a great deal of flexibility and choice when it comes to accessing healthcare. However, it’s important to carefully consider your healthcare needs and budget when choosing a PFFS plan, as they may not be the most cost-effective option for everyone.

The PFFS does not fill in for Medicare Supplement insurance and providers that decide not to contract with the PFFS plan do not have to treat you, unless the treatment needed is an emergency. Be sure you talk with healthcare providers ahead of time to see if they will agree to the bill plan and will treat you. 

Special Needs Plans

Medicare Special Needs Plans

A Medicare Special Needs Plan is another type of Medicare Advantage Plan. This plan is only for those who have a specific disease or health condition. Not only that they work around the client to best meet the needs of the person on the plan. 

Who you can receive healthcare from

Care and services must be through the doctors and hospitals within the Medicare SNP network. The people on SNP go to specialists who deal specifically with diseases and conditions they might have. 

Drug Coverage

With a Medicare Special Needs Plan, it is mandatory that they provide Medicare drug coverage. 

Primary Care Doctor

With the SNP plan, choosing a primary care doctor will be required, or choosing a care coordinator to help with health care can be made. 


A referral is needed to see any specialists within the SNP network. You do not need a referral for a yearly mammogram screening or a pap test and pelvic exam that is in-network. 

What you need to know

The planned membership is limited only to certain groups that meet the criteria to apply;

  • Those who live in health institutions, and or need assistance with living at home
  • Those eligible for Medicaid and Medicare
  • Those with chronic or conditions that disable the person from being well, ex. (HIV/AIDS, Dementia, etc.) 

If one is one Medicaid and Medicare then be sure to check and see if healthcare providers accept Medicaid. Make sure to do research to see if the SNP providers are within the area you reside in.