How Medicare Advantage works
You remain in Medicare, but a private Medicare-approved plan administers your Part A and Part B benefits. Most plans also include Part D prescription drug coverage, and many offer additional benefits not covered by Original Medicare.
HMO, PPO and other plan types
| Type | General idea |
|---|---|
| HMO | Usually emphasizes in-network care, except emergencies/urgent care and certain exceptions. Referrals may apply. |
| PPO | Usually allows both in- and out-of-network care, but out-of-network services can cost more. |
Plan rules vary, so the actual Evidence of Coverage and provider directory matter more than the letters HMO or PPO alone.
What to check before enrolling
The maximum out-of-pocket limit matters
Medicare Advantage plans have a yearly limit on what you pay out of pocket for covered Part A and Part B services. Once you reach the plan's applicable limit, the plan pays 100% for covered Part A and B services for the rest of the year. Compare that protection along with copays and premiums.
Plans can change each year
Premiums, networks, formularies, copays and extra benefits can change from one year to the next. Read your Annual Notice of Change and review your coverage when something important changes.
Official reference: Medicare — Compare coverage options.
Still have questions?
Medicare is personal. If you want help understanding how these rules fit your situation, Mike & Tracy can walk through it with you. There is no additional cost for our assistance.