Two ways to get Medicare
A glimpse of Medicare Advantage choices
Let’s start with the basics. You can choose between two ways of receiving your Medicare benefits. You
can receive your benefits directly through Original Medicare with options for additional insurance, or
you can choose a Medicare Advantage plan that combines your benefits.
Medicare Advantage plans come in several different forms. The plans you’ll see most often are Health
Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). There also are some
newer types of plans like Special Needs Plans (SNPs) and Private Fee-for-Service (PFFS). Let’s take a
closer look.
Original Medicare
is operated by federal government
subcontractors. Medicare pays fees for
your care directly to the doctors and
hospitals you visit.
Coordinated Care Plans
Accessing Medicare Directly
through Original Medicare
Part A gives you help
with hospital costs.
Part B helps with
doctor’s care and
outpatient care.
Part D stand-alone
prescription drug plans
can be added to help
with the cost of
prescription drugs.
Medigap (Medicare
supplemental insurance)
policies can be added to
fill in some of the gaps
in Part A and
Part B coverage.
Medicare Advantage Plans
are private health plans that contract with
Medicare. For many people, Medicare Advantage
plans are a good value because they can offer
health benefits (like those detailed below) at low
or no additional monthly plan premium beyond
the Medicare Part B premium.
Accessing Medicare through
Medicare Advantage Plans (Part C)
Medicare Advantage plans offer
the same coverage as Original
Medicare Parts A and B, plus
more. Medicare pays a fixed fee
to the plan for your care, and then
the plan handles its own payments
to doctors and hospitals. To join,
you must also belong to Part B.
Part D prescription drug coverage
is integrated with many Medicare
Advantage plans. If you are in a
private fee-for-service plan without
drug coverage, you may be able to
choose a stand-alone drug plan.
Additional benefits are often
included, such as vision services,
hearing services, health screening
tests and nurse helplines. And
some plans cap your out-of-pocket
spending for the year.
HMOs, PPOs and SNPs are often referred to as “coordinated care” plans. These plans are built on the
idea of doctors and hospitals working together to coordinate and facilitate your care. Each plan creates
its own network.
HMO plans provide care through a broad group, or network, of local doctors and hospitals. Your primary
care physician may oversee your care and, in some cases, refer you to specialists as necessary. Some
plans give you the ability to see specialists without referrals. You may save the most money on your
health care costs by joining an HMO; however, your choice of health care providers is more limited than
with other plans. Some plans have point-of-purchase options in which you can see doctors and hospitals
outside the network at a higher
cost-sharing.
PPO plans generally provide more flexibility
to let you choose your doctors and hospitals.
These plans typically don’t require you to have
a referral to see a specialist, and you can see
doctors outside the network without having
to pay the entire cost yourself. If you do visit a
doctor or hospital outside the network, though,
you’ll usually pay a larger share of the cost of
your care.
SNP plans offer individual attention for people
with complex health needs. These plans are
designed to serve people with special needs
like those living in nursing homes, those with
chronic conditions like diabetes or congestive
heart failure — or those who qualify for both
Medicare and Medicaid.
Private Fee-For-Service
Plans (PFFS)
PFFS plans are different from HMO,
PPO and SNP plans. Typically, PFFS
plans do not use networks of doctors
and hospitals. Instead, you can choose
any doctor or hospital — anywhere in
the U.S. — that is willing to accept the
plan’s payment terms and conditions.
Some doctors and hospitals do not
accept PFFS plans or only accept
certain ones. It is important to
confirm that the provider is willing to
accept the plan’s payment terms and
conditions each time before receiving
services. Otherwise, you may have to
pay up to the full amount of the cost of
your care.
Plan pays
most of
the cost of
services and
you pay a
share.
Prescription Drug Coverage
With each of the Medicare Advantage plan types — HMO, PPO, SNP and PFFS — you may have the
opportunity to receive prescription drug coverage (Medicare Part D). Many people find it convenient to
have their hospital, medical and prescription drug coverage all in one plan. Most plans do not charge an
extra premium to have prescription drug coverage.
Plan pays a
bigger share
for services
inside
network.
You pay all or most of
the cost of services
outside network.
When your Medicare Part D prescription drug coverage is included in your Medicare Advantage plan, it
works the same way as if it were a separate plan. You will pay a portion of the cost of your drugs and that
portion will change depending on the drugs you take and what you (and your plan) have spent during
the year. Your exact costs will vary from plan to plan.
Note: You cannot have both a separate Medicare Prescription Drug plan AND a Medicare Advantage
plan that includes prescription drug coverage. The government only allows you to have one Medicare
prescription drug plan at a time.
Seven big ideas about Medicare Advantage
1. You get the convenience of a single plan
With a Medicare Advantage plan, you may be able to choose a single plan that covers hospital care,
doctor’s care and prescription drug coverage too. You could have only one plan to choose, and one
plan to keep track of.
2. You’ll get additional benefits
Medicare Advantage plans offer the same coverage as Original Medicare Parts A and B, plus extras
that contribute to your health and wellness. Some examples are annual physicals, vision care and
access to a nurse helpline. Many, but not all, even include a Part D prescription drug plan. Many
plans also offer a cap on your annual out-of-pocket spending.
3. Different choices are available
Medicare Advantage plans are available in several different versions, including plans for those
with special needs. All are offered by private insurance companies that are required to meet or
exceed Medicare standards. There’s a good chance you’ll find one that matches your needs.
4. Most people qualify
Generally, Medicare Advantage plans are open to everyone who’s eligible for Medicare and who
lives in the service area of the plan regardless of health or finances, with the exception of people
with end-stage renal disease. There are no physicals or health questions. You can’t be refused,
even if you have pre-existing conditions that might mean you are a greater risk, and your premium
is not affected.
5. Your Part B premium may be your only premium
If you join a Medicare Advantage plan, you will still pay your usual monthly payment for Part B.
Some plans don’t charge any additional premium, although some plans do. Each year, prices
change, but because companies compete for your business they work hard to keep premiums low.
6. You’ll pay a share of your costs
With a Medicare Advantage plan, you’ll pay a share of your costs as you use services. Each plan
has its own rules for deductibles, copayments and other cost sharing, which may be different from
the cost sharing in Original Medicare. Some Medicare Advantage plans will even limit your out-ofpocket spending, a feature not offered with Original Medicare.
7. Where you live matters
Most Medicare Advantage plans focus on a specific geographic area, like a county, state or region.
Not every plan is available everywhere.
Depending on the plan type, Medicare Advantage plans may build networks of doctors and
hospitals in their service area. Not all doctors participate in Medicare Advantage plans. If keeping
your doctors is important to you, check with them to see if they accept the plan you
are considering.
If you travel a lot, you’ll have coverage for emergency care, urgent care and renal dialysis when
you’re away from home in the U.S. Some plans provide emergency coverage worldwide.
Plan carefully. Decide with confidence.
Choosing your Medicare coverage takes some thought and planning. Here are steps you can take that
will help you compare plans and choose one that meets your needs and preferences.
1. Research your options to learn what plans and policies are available in your area. To find out
more about which plans are available in your area, visit www.medicare.gov to access the Medicare
Personal Plan Finder. You can also learn about plans in your area from your local State Health
Insurance Assistance Program (SHIP). Call the Medicare Helpline at 1.800.MEDICARE (1-800-6334227), TTY: 1-877-486-2048, 24 hours a day, 7 days a week, and ask for the telephone number of your
state’s SHIP program.
2. Compare your choices. Because each Medicare Advantage plan is a little different, you may want
to create a worksheet that compares the choices you are considering. A worksheet can help you track
details like extra benefits, premiums, deductibles and cost sharing. You will also find it helpful to keep
your enrollment options in mind. If you’re turning 65 or are otherwise newly eligible for Medicare,
you can sign up right now for a Medicare Advantage plan. If you are already enrolled in Medicare,
you can select a Medicare Advantage health plan during the annual election period from November
15 through December 31 each year. And if you’re already enrolled in a Medicare Advantage plan, you
have an additional opportunity to make a change of plans from January 1 to March 31 each year.
3. Call the plan’s customer service number for help if you have questions about the plans
you’re considering. They may be able to answer your questions quickly on the phone. Or make an
appointment to talk with a plan representative about your questions.
The AARP® MedicareComplete® plans are SecureHorizons® Medicare Advantage plans insured or covered
by an affiliate of UnitedHealthcare, an MA organization with a Medicare contract. AARP is not an insurer.
UnitedHealthcare pays a fee to AARP and its affiliate for use of the AARP trademark and other services. Amounts
paid are used for the general purposes of AARP and its members. The AARP® MedicareComplete® plans are
available to all eligible Medicare beneficiaries, including both members and non-members of AARP. AARP and
the AARP Logo are trademarks or registered trademarks of AARP. The SecureHorizons and MedicareComplete
marks are trademarks or registered trademarks of United Healthcare Alliance, LLC and its affiliates.
AARP does not make health plan recommendations for individuals. You are strongly encouraged to evaluate
your needs before choosing a health plan.
A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. Your
doctor or hospital is not required to agree to accept the plan’s terms and conditions, and thus may choose not to
treat you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms
and conditions, they may choose not to provide health care services to you, except in emergencies. Providers can
find the plan’s terms and conditions on our Web site at: www.securehorizons.com.
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Medicare Advantage
Explained