Medicare Advantage is a cost-saving option for seniors in Illinois, providing coverage that helps with the cost and coverage gaps in Medicare. Understanding the differences between the various plans will help you make an informed decision. Factors like cost, referrals, and whether or not you can use hospitals and doctors outside a plan’s network.

Health Maintenance Organizations

An HMO plan typically requires that you select a primary care doctor from the plan’s network of providers. In most cases, you’re required to use doctors, health care providers, and hospitals within the plan’s network, except in an emergency. You may need a referral to see a specialist. Compared to other plans, this plan can be a cost-effective option, but you may pay the full cost of care if you do not follow the rules. Prescription drug coverage is usually covered but individual plans vary.

Preferred Provider Organizations

PPOs tend to be less restrictive than HMOs, but increased flexibility can cost you more. You do have the option to use any doctor, specialist, or hospital you choose, but you will pay less if you stay within the plan’s network. A referral is generally not required to see a specialist. Prescription coverage is often covered, but individual plans vary.

• Private Fee for Service

  The type of plan decides how much it will pay doctors and hospitals, and how much you will pay. If the plan has a network of providers, you don’t need to go to doctors or hospitals on the list. However, not all Medicare providers accept this plan. Typically, with a PFFS, you do not need to get a referral to see a specialist. Prescription coverage may be covered, but plans vary.

• Special Needs

  Membership in a Special Needs Plan is limited to people with specific diseases or who have specialized health needs. If you have a severe chronic condition, live in a nursing home, or receive both Medicare and Medicaid, you may be eligible.

There are also Provider Sponsored Organizations (PSOs), and Medicare Medical Savings Accounts (MSAs). Regardless of the type of plan, all cover all Medicare services. They’re required to offer at least the same benefits as Medicare, but most offer more. Many plans include benefits for dental, vision, and prescriptions, benefits not offered through Medicare. 

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References:

https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/different-types-of-medicare-health-plans-.html

https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/types-of-medicare-advantage-plans.html

HMO: https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/hmo-plans.html

PPO: https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/preferred-provider-organization-plans.html

PFFS: https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/private-fee-for-service-plans.html

SNP: https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/special-needs-plans.html

MSA: https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-savings-accounts/medical-savings-account-plans.html