Laying a Solid Foundation | Lesson 3

Types of Medicare Advantage Plans

Although Medicare Advantage plans are popular among today’s seniors, they are not one-size-fits-all. There are many different types of Medicare Advantage plans. As an agent, it’s important to have a diverse portfolio of these products to best meet your clients’ varied needs.

We’ll go through the different options, review their characteristics and which clients they benefit.

Let’s start with the HMO, or health maintenance organization. An HMO is a type of plan that requires beneficiaries to use in-network providers for all non-emergency services. HMOs aim to have beneficiaries’ medical care go through their primary care physician (PCP). Because of this, HMOs require a client to select a PCP when they enroll, and often require a beneficiary to see their PCP for a referral before seeing a specialist. Since they are using only in-network providers for their care, HMO beneficiaries usually have lower out-of-pocket costs.

HMOs tend to be a good fit for clients with access to strong provider networks and those who value lower costs over network flexibility. One last note on HMOs, you may run into something called an HMO-POS plan. The POS stands for point-of-service, allowing beneficiaries to get some services out of network for a higher copay or coinsurance.

Up next, we have the preferred provider organization or PPO. PPOs still have a network of providers, but they also cover beneficiaries for services they receive from out-of-network providers. However, beneficiaries will usually pay more when using out-of-network providers. Because of this flexibility, PPOs usually don’t require a client to select a primary care physician when enrolling, and don’t require a referral to see a specialist.

PPO plans are a great fit for clients who enjoy the perks of a flexible network and are okay with spending a little more out-of-pocket if needed.

Next up, similar to the PPO, Private-Fee-for-Service plans also offer flexibility with provider options. A Private-Fee-for-Service product sets prices for what the plan will pay for medical services and what the beneficiary will pay for those services. A beneficiary in one of these plans can see any provider that accepts the plan’s payment rates. Some Private-Fee-for-Service plans set up a network that has agreed to always accept the plan’s payments. If your client plans on using an out-of-network provider, they should contact that provider first to ensure that they will accept the payments in the plan.

Another unique type of Medicare Advantage Plan is the Medicare Medical Savings Account plan or MSA. MSA plans pair a high deductible Medicare Advantage plan with a medical savings bank account. With this product, beneficiaries pay the Medicare-approved amount for their medical services until they hit their deductible. Once they hit their deductible, the MSA plan would cover 100 percent of the costs for Medicare-covered services. To help beneficiaries cover the cost to reach the deductible, an MSA plan deposits a set amount of funds into the beneficiary’s medical savings bank account. These funds can be used to pay for qualified medical expenses like doctor visits or prescription drugs.

MSA plans usually don’t have a network, so beneficiaries can see any provider that accepts Medicare assignment. These products are a great fit for clients who are in relatively good health and have the funds available to cover their out-of-pocket exposure. One thing to keep in mind with MSA plans is that they don’t cover prescription drugs. If your client enrolls in an MSA, they’ll also need to buy a stand-alone PDP if they don’t have other creditable drug coverage.

The last group of plans we’ll cover here are the special needs plans or SNPs. SNPs are a type of Medicare Advantage plan that are designed to meet the unique needs of individuals with a special circumstance or characteristic.

There are three different SNPs: D-SNPs, C-SNPs, and I-SNPs.

D-SNP stands for Dual Eligible Special Needs Plan and is designed for clients who are eligible for both Medicare and Medicaid. D-SNPs are designed to minimize out-of-pocket expenses, and add valuable services to help clients access care to stay well.

C-SNPs are Chronic Condition Special Needs Plans. These plans are designed for clients that are eligible for Medicare and suffering from one or more qualifying chronic conditions, like diabetes. C-SNPs will tailor their coverage, including network and formulary, to give greater access to the providers and medications needed to treat the chronic condition.

The last SNP is the I-SNP or Institutional Special Needs Plan. The I-SNP is designed for clients who are eligible for Medicare and live in an institution like a nursing home or long-term care facility.

There is much more to be said about these Special Needs Plans, so be sure to check out our Understanding Special Needs Plan module to learn more! Of the plans discussed in this lesson, HMOs and PPOs are the most common Medicare Advantage plan types.

We’d recommend having at least one HMO and one PPO in your portfolio, and including the other plans mentioned as you see opportunity and need in your market.

Now that you understand the different types of Medicare Advantage plans, head over to our next lesson to learn about the costs in these plans.

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