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Advantage Plans

Types of Medicare Advantage Plans

There exists an array of Medicare Advantage plans, each flaunting its idiosyncrasies. When selecting a Part C plan, it’s imperative to comprehend their distinctions to select the optimal match. There are five categorizations of Medicare Advantage plans to mull over.

The Five Types of Part C Plans

Medicare Advantage plans are sorted into five distinct categories.


Health Maintenance Organizations


Preferred Provider Organizations


Special Needs Plans


Private Fee-for-Service Plans


Medical Savings Account Plans

Each of these schemes aims to bridge the lacunae in coverage left by Original Medicare. Despite sharing a common objective with Medicare supplement plans, they diverge significantly.

Medicare Advantage and Enrollment Criteria

To meet all qualifying requirements for a Part C plan, one must be signed up for Medicare Parts A and B. Save for people suffering from End-Stage Renal Disease (ESRD); meeting this norm renders one qualified for a Part C plan.

Age Requirement:
– Individuals must be 65 years old or older.

Medicare Part A and Part B Enrollment:
– Prospective enrollees must be enrolled in both Medicare Part A (hospital insurance) and Part B (medical insurance).

Residency Status:
– Eligibility is generally open to U.S. citizens and legal residents who have lived in the country for at least five consecutive years.

Not Having End-Stage Renal Disease (ESRD):
– Individuals with End-Stage Renal Disease (ESRD) typically do not qualify for Medicare Advantage, though there are some exceptions.

Plan Availability in the Area:
– Enrollees must reside in a geographic area where Medicare Advantage plans are offered.

Enrollment Periods:
– Eligible individuals can enroll during specific periods such as the Initial Enrollment Period (IEP), Annual Enrollment Period (AEP), or Special Enrollment Periods (SEP) based on qualifying events.

Active Medicare Part C Plan Selection:
– To enroll in Medicare Advantage, individuals must actively choose a Part C plan offered by a private insurance company that has been approved by Medicare.

It’s important to note that specific eligibility criteria may vary, and individuals should verify their eligibility based on their unique circumstances.

Medicare Advantage Costs

Presently, around 30% of Medicare beneficiaries opt for Medicare Advantage plans instead of Medicare supplements, primarily driven by cost considerations. Medicare Advantage plans generally feature significantly lower premiums. Nevertheless, it’s crucial to note that regardless of the chosen plan, individuals are still accountable for the Medicare Part B premium.

When enrolled in a Medicare Advantage plan, your insurance carrier takes charge of your medical bills. While you’re responsible for the costs of services received from healthcare providers, including copays stipulated by the plan, the plan itself plays a pivotal role in managing your overall medical expenses.

Medicare Advantage and Drug Coverage

Dive into the Medicare Advantage groove! While most Part C plans are your one-stop-shop for health coverage, jam-packed with prescription drug benefits, it’s key to hit the right notes. Tune in to your plan’s drug formulary to ensure your meds are on the playlist.

Now, let’s take a quick spin through the Medicare Advantage plan lineup!

Health Maintenance Organizations


Medicare beneficiaries enrolled in an HMO must seek treatment exclusively from in-network providers, as these plans extend no coverage beyond their established network, barring emergencies. Should an HMO member seek care outside the network, they bear full responsibility for all expenses.

While there exist a few HMO plans permitting limited out-of-network benefits, their premiums surpass those of traditional HMO plans.

Within an HMO framework, individuals must secure a referral to consult a specialist and appoint a primary care physician.

On occasion, a provider may opt to withdraw from the plan’s network. In such instances, the plan will inform you, necessitating the selection of a new provider.

Preferred Provider Organizations


A PPO operates akin to an HMO plan, albeit with a singular contrast. While it’s better for PPO members to get treatment from providers and facilities within the network, there are still benefits to getting care outside the network.

Using the PPO network gives members the best coverage. However, it’s still okay to get care outside the network, albeit the arrangement will cover fewer benefits, leading to higher personal expenses for the member.

PPO members don’t have to choose a primary care doctor and are not required to get referrals to see specialists.

Private Fee-for-Service Plans


PFFS schemes diverge significantly from other variants of Medicare Advantage plans. In a PFFS plan, a beneficiary partakes in the flexibility of seeking care from any provider or facility that agrees to the plan’s payment agreements. Nevertheless, not all providers will endorse these terms and may opt out of them at their discretion. Like PPO plans, PFFS plans exempt their members from the obligation to designate a primary care doctor or secure a referral to consult a professional. The costs associated with these plans will, in general, be higher than HMO plans due to the more extensive cluster of out-of-network care choices accessible to members. However, physicians who refuse to honor the plan’s payment terms also reserve the authority to decline treatment to patients with PFFS plans.

Special Needs Plans


SNPs cater exclusively to Medicare beneficiaries afflicted with specific ailments or disabilities. These plans tailor their selection of physicians, benefits, and drug formularies to align with the medical requirements of the targeted group.

SNPs maintain a roster of specialized doctors whom their members must consult for their healthcare needs. While plan members are encouraged to seek care from these doctors, coverage is extended for emergency care received outside the network.

All Special Needs Plans must adhere to the following criteria:

  • Incorporate prescription drug coverage
  • Mandate the designation of a primary care physician and a care coordinator
  • Demand a referral for specialist consultations
  • Cover annual mammogram screenings, Pap tests, and biennial pelvic exams

Upon qualification for an SNP, Medicare beneficiaries can enroll at any time, granting them access to a Special Enrollment Period.

Individuals enrolled in an SNP plan benefit from coordinated services and providers, which enhances the effectiveness of their treatment outcomes.

Those eligible for both Medicare and Medicaid should ensure that all physicians under their SNP plan also accept Medicaid. Residents of institutions should verify the facility is included in the plan’s coverage.

Medical Savings Accounts


You might have caught wind of HSAs or Health Savings Accounts, which are for people with high-deductible clinical coverage plans. If you’re qualified, you can deposit pre-tax money in a savings bank account to use later for qualified medical services costs.

A Medicare Medical Savings Account (MSA) bears resemblance to an HSA but is exclusively accessible to those enrolled in a high-deductible Medicare Advantage plan. In an MSA, the plan allocates funds into the member’s savings account, which can be utilized for healthcare expenses before settling the plan’s deductible.

Explore Further Into the Varieties of Medicare Advantage Plans

We trust we have provided you with a fundamental grasp of the various Medicare Advantage plans. There are myriad factors to weigh when enrolling in such plans, and consulting with a well-informed agent regarding your choices is advisable.

Consult an Advisor

Here at California Medicare Agency, we are dedicated solely to Medicare. Our brokers, boasting an average of 10 years of expertise, prioritize providing you with comprehensive education, ensuring all your decisions are well-informed.

We have no affiliation or endorsement from the United States government or the federal Medicare program. Our range of plans may not encompass every option in your vicinity, and the information we furnish is restricted to the plans we offer. For comprehensive information on all available options, please reach out to or call 1-800-MEDICARE. Health insurance purchased via is processed through the licensed entity: Connor.

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