Medicare Advantage/PPO/Fee For Service/HMO

Eligible participants are individuals who have Medicare Part A & B. Medicare Advantage Plans may provide additional medical and pharmacy benefits that are currently not covered by Medicare Part A and B.

Some companies offer Private Fee-For Service Medicare Advantage Plans.

These plans do not require participants to use a network provider. Fee-For-Service plans are becoming more popular because of flexibility and ease of use. These plans offer nationwide coverage with no referrals needed. Premiums are usually much less than Medicare Supplement plans.

If you stay near home most of the time you may want to enroll in an Health Maintenance Organization (HMO)

These plans usually require you to use network providers and you may need a referral to see a specialist. If you decide to enroll in an HMO plan make sure you obtain a list of providers so you can check the quality and availability of Doctors and Hospitals in your area.

One other type of Medicare Advantage Plan is commonly referred to as a PPO

Also known as a Preferred Provider Organization. Generally speaking, this is a network program that may allow you to use out of network providers with a higher co-pay or a co-insurance. Rates will vary.

How do Medicare Private Fee-for-Service Plans work?

Generally, you get care in the United States from any Medicare-approved provider such as a doctor or hospital who, before treating you, agrees to accept the Medicare Private Fee-for-Service Plan’s terms and conditions of payment. You must show your plan membership ID card every time you visit a health care provider. There is a telephone number or website on the card for the provider to find out about the plan’s terms and conditions of payment. This gives your provider the right to choose whether to accept the plan’s terms and conditions of payment. If you need emergency care, it is covered whether the provider accepts the plan’s payment terms or not. If you join a Medicare Private Fee-for-Service Plan, not all providers will accept the plan’s payment terms or agree to treat you. Before you get any services, ask your doctor or hospital if they are willing to contact the plan for payment information and accept the plan’s payment terms.

How do my out-of-pocket costs vary?

Each year, Medicare Private Fee-for-Service Plans establish the amounts they charge for premiums, deductibles, and services. The Medicare Private Fee-for-Service Plan (rather than the Medicare Program) decides how much you pay for the covered services you get. What you pay the plan may change only once a year on January 1. Your costs depend on which Medicare Private Fee-for-Service Plan you choose, whether the plan charges an additional monthly premium,how much the plan charges for your services,whether the plan lets doctors, hospitals, and other providers bill you more than the plan pays (up to a limit) for services (If this is allowed, you must pay the difference,how often and the type of health care you get,which extra benefits are covered by the plan, and whether you see out-of-network providers in a Medicare Private Fee-for-Service Plan with an established network of contracted providers.

How do I pay my bills (such as a doctor or hospital bill)?

If you get covered health care services from a provider, you are only required to pay the co-payment or coinsurance amount allowed by the plan for the type(s) of service you get, at the time of the service. The provider will bill the plan for the remaining amount according to the plan’s payment terms. If you get a bill for services, you can send the bill to the plan for the plan to pay its share of the cost to the provider. The plan will let you know if you must pay a share of the costs. (If you paid for the covered services, the plan will reimburse you for its share of the cost.) Note: If you have any questions about whether the Medicare Private Fee-for-Service Plan will pay for a certain health care service, you can ask the plan for a written advance coverage decision before you get the service. The plan will let you know if it will pay for the service.

Do Medicare Private Fee-for-Service Plans cover extra benefits?

Medicare Private Fee-for-Service Plans may have extra benefits the Original Medicare Plan doesn’t cover, such as some vision, hearing, dental, and/or prescription drug coverage. However, you may have to pay more for these extra benefits.

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