Medicare Advantage Plans

Like traditional medical insurance, Medicare Advantage Plans have doctor & hospital networks. These networks can be a good thing because they negotiate and help contain medical costs for members. There are several types of Medicare Advantage Plans, but two are most common; HMO and PPO. Here are the key features and differences between the two types of plans.

PPO – Preferred Provider Organization

Has a nationwide network of preferred doctors & hospitals. The plan allows you to go to out of network doctors for higher co-pays.
You are covered anywhere in the event of an emergency or urgent care situation.
You don’t need a referral to see a specialist doctor.
Best if you travel or want more flexibility and choice with seeing healthcare providers.

HMO – Health Maintenance Organization

Has a local, multi county, network of preferred doctors & hospitals. You need to use this network of doctors & hospitals for scheduled medical care.
You are covered anywhere in the event of an emergency or urgent care situation.
You will need a referral to see a specialist doctor.
Best if you want the most benefits at the lowest cost and are good with using the plan’s doctors.

Many doctors & hospitals accept Medicare Advantage PPO and HMO plans.

Sample Medicare Advantage Plans

Below are sample plans that mirror many popular plans available in Texas. If you look closely you see the slight differences between the plans.

HMO Medicare Advantage Plans

Coverage for hospitalization, nursing facility, and other Part A benefits.

Coverage for doctors, outpatient care, and other Part B benefits. You’ll need to use the plan’s network of doctors except for emergency or urgent care.

Referrals are needed from your primary care doctor to see specialists

$0 monthly premium. You only pay the Medicare Part B premium.

$0 deductible or co-pay for annual in network preventive care and exams.

$0 deductible for diagnostic medical care, treatment, & tests; You only pay co-pay’s or coinsurance.

$0 co-pay for primary doctor, $30 specialist, $90 emergency room.

Maximum annual out of pocket included for your financial protection. This is the most you pay out of pocket for medical bills during the calendar year. Maximums vary depending on the plan.

Includes Part D prescription benefits and coverage for generic, brand, & specialty medications.

Dental, vision, & hearing aid benefits included.

No cost health club membership & exercise programs.

PPO Medicare Advantage Plans

Coverage for hospitalization, nursing facility, and other Part A benefits.

Coverage for doctors, outpatient care, and other Plan B benefits. This plan has a network of doctors & hospitals, but you can go out of network for higher co-pays.

No referral is needed from your primary care doctor to see specialists.

$18 monthly premium in addition to your Medicare Part B premium.

$0 deductible or co-pay for in network preventive care and exams.

$0 deductible for diagnostic medical care, treatment, & tests; You only pay co-pay’s or coinsurance.

$0 co-pay for primary doctor, $40 specialist, $90 emergency room.

Maximum annual out of pocket included for your financial protection. This is the most you pay out of pocket for medical bills during a calendar year. Maximums vary depending on the plan.

Includes Part D prescription benefits and coverage for generic, brand, & specialty medications.

Dental & vision benefits included.

No cost health club membership & exercise programs.

Medicare Advantage benefits are similar among the different insurance providers. The details can make a difference in finding the best plan for you.

CLICK HERE and request information and guidance on specific plans & insurance providers available to you.

Honor Plans

There are Medicare Advantage options for Military and Veterans called “Honor Plans.” These plans can give you more benefits and a lower premium than Original Medicare.

3 Tips To Find Your Best Medicare Advantage Plan

1. Compare Plans & Providers Available In Your County – In any particular county, there is usually a variety of plans offered by different insurance providers. The extent of this variety depends on where you are. In any case, you can compare available benefits and providers. Plans offered among the different insurance providers can often be similar. By reviewing the details, you may find some are better than others. You can review the “Summary of Benfits” for the different plans you are interested in. This is a document that lists the benfits you get as a member and your out of pocket costs. Medicare also provides a “Star Rating” for each plan. This rating is generated each year through Medicare’s research and feedback from the plan’s members.

2. Find Out About Network Doctors, Hospitals, & Providers – Medicare Advantage plans have networks, which are lists of doctors & hospitals that accept the plan. With HMO plans you need to use doctors & hospitals that are in the plan, except in cases of emergency or urgent care. With PPO’s you pay lower co-pays at network doctors and have coverage at out of network doctors for higher costs. In either case, you’ll want to use network doctors to keep your medical costs down. For any plan you are interested in you can check their network directory for the doctors and hospitals that accept the plan. If you have doctors that are important to you, you can also check the network to see if they are in it.

3. Compare How Plans Cover Medications – Most Medicare Advantage plans include Part D prescription coverage with them. This is with the exception of plans that do not have prescription coverage, which are designed for those who will have it through another source. Each Advantage Plan available in your area may cover different medications, at different costs. You can review the “Formulary” to see what medications are covered and estimate the costs of your medications. If you have a preferred pharmacy, you will also want to know what pharmacy’s are covered. Each plan has a pharmacy network and certain pharmacies where costs for your medications may be lower. Most plans also offer 90 day home delivery for certain medications. If you are open to or prefer delivery, you can check the cost of your medications using this method.

Bonus Tip: Get Help

Finding your best plan can be confusing and time consuming. It can be hard finding the tools and information you need to make a good decision. Working with a good, reputable Independent Agent can help you simplify the process. Just like any specialist, they can help you get what you need much easier and faster.

7805 Cooper Ln. Suite #209

Austin, TX 78745

855-625-7633 Toll-Free Phone

Insurance Licenses

TX #2495139, AZ #3001852513, AR #3001409811 VA #147897, OH #1285673 TN #2475437, SC#3000813771, LA #867655, FL #11741456

We are an independent agency that offers a variety of plans & insurers. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-Medicare to get information on all your options.