Taking care of one’s health is in their own hands. Knowing there is security regarding your and your family’s health; gives you relief and satisfaction. People now opt for medical plans.

Medicare Advantage Plan is an excellent way to get Medicare for both parts A and B cover. These plans, sometimes called “Part C” or “MA plans,” are provided by all those private companies which are Medicare-approved.

Such companies are supposed to follow specific rules established by Medicare. Several Medicare plans also include Part D, which covers the drug area. You will need to hire a healthcare provider who participates in the plan’s network. These plans limit how much you spend each year for all the covered services.

A few other plans put forward non-emergency off-grid coverage, but they usually are costly. Remember, you must use a Medicare Advantage Plan card to receive eligible Medicare benefits. Keep your white, blue and red Medicare cards safe, as some services may require you to have your Medicare card, which you are meant to use there. You will also require it if you go back to Medicare.

In this extensive article, you are going to learn all about the three main plans and what all cover.

HMO: Health Maintenance Organization Plans


In this type of plan, you are provided with your care and other services from health care providers, doctors, and all the hospitals which are available in the network of the given plan, except:

HMO Point-of-Service (HMO-POS) services are those HMO schemes that may allow a person to get some services that are out-of-network for a much higher coinsurance or copayment. It’s very crucial to note that you follow all the rules of a given plan, such as having prior approval for a particular service whenever there is a requirement by the plan.

Are Prescribed Drugs Covered?

In several situations, HMO plans do cover prescription drugs. It would help if you asked about it. If you want your plan also to cover Medicare drug coverage (Part D), then go for the HMO plan that provides prescribed drug coverage. If one joins an HMO that does not cover drugs, he cannot go for a separate drug policy.

Is It Required To Choose A Doctor?

When choosing a doctor, you are supposed to choose a primary care doctor when you opt for an HMO scheme.

Does One Have To Get A Referral To Consult A Specialist Doctor?

Mostly, you are supposed to get a referral if you want to see a specialist in such plans. Few services do not require you to get a referral, such as annual screening mammograms.

Other Points:

If a person’s healthcare provider or doctor decides to leave the scheme, it will notify you of such a situation. Then you have to go to another doctor.

If a person opts for complete health care outside the plan’s network, they are required to pay the total amount.

You must follow every rule of it, such as getting approval before for a particular service whenever needed.

PPO: Preferred Provider Organization Plans


How Do These Plans Work?

A PPO is a kind of Medicare Advantage Plan (Part C) provided by a private insurance company. These plans have several network doctors, hospitals and health care providers. If you go for doctors that are present in the plan’s network, then you pay much less. But if you go for a doctor outside the network for all the covered services, you have to pay much higher if they agree to give you treatment and haven’t opted out of any Medicare, Part A and B services. You are covered for urgent and emergency care.

Can One Go For Another Doctor Or Health Care Provider, Or Hospital?

In many situations, you usually get your health care from any hospital and doctor present in the PPO plans. Each of these plans provides you with the flexibility to go to specialists, doctors or hospitals that are not in the plan’s network but will cost you much more.

Are Prescribed Drugs Covered?

In some situations, prescribed drugs come under the PPO plans. Ask about the plan when you go for it. If you want Medicare drug coverage, you should join a PPO plan that provides prescribed drug coverage. If you do not go for a PPO plan that doesn’t cover the drugs, you cannot join a Part D Medicare drug plan.

Is One Required To Choose A Primary Doctor?

You can choose an essential care doctor in some of the PPO plans.

Does One Need To Have A Referral To Consult A Specialist?

In most situations, no. But if one uses plan specialists (in-network), your bills for all the covered services will be much lower than if one uses non-plan specialists, which means they are out of the plan’s network.

PFFS: Private Fee-for-service Plans


How Do They Work?

A Medicare PFFS is a kind of advantage plan of Medicare (Part C) that a private insurance organization or company provides. It determines what amount it will pay all the doctors, hospitals and other care providers and how much one must pay for when they get care. These plans are not the same as Medigap or Original Medicare.

Can I Get Care From Any Doctor Or Care Provider?

In a few situations, one gets care from any doctor, hospital or care provider in all the PFFS plans. If you opt for a PFFS with a particular set of providers, you can go for any network doctors who agree to give treatment to plan members. If you consult a doctor, health care provider, hospital, supplier or facility that does not come under the plan’s network for non-urgent or non-emergency care services, the plan may only cover some of those services, which could lead to higher costs.

Are Prescribed Drugs Covered?

PFFS Plan covers prescribed drugs, but if your plan does not cover them, you can go for a different Medicare drug plan (Part D).

Do You Need To Select A Primary Care Doctor?

You are not required to choose a doctor under PFFS Plans.

Do You Need To Have A Referral To Consult A Specialist?

You don’t have to provide a referral to see a specialist.

Other Points:

This plan determines what it costs you to pay for the services. It will also tell you about all the cost-sharing present in evidence and notice of change papers which it sends yearly.

Some plans contract with a set of providers who have agreed for the network and will always treat you, even if you have never seen them.


To conclude, this was all about Medicare plans and all the essential information that one might need to decide which plan they want to go for. Make sure you grab all the necessary documents and check that everything is up to date before you sign up for your choice of plan.


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