Know the different Network types of Medicare Advantage Plans

‘Networks’ in Medicare Advantage Plans can be found to be of three different types. They are:

  • HMO Plans (Health Maintenance Organization)
  • PPO Plans (Preferred Provider Organization)
  • PFFS Plans (Private Fee for Services)

The smallest provider network is HMO Advantage, since they have limited number of facilities, hospitals and doctors. PPO network has wide range of facilities, hospitals and physicians, thus allowing individuals requiring care with plenty of options to choose from, something not offered with small HMO network. PFFS represents the biggest group of facilities, hospitals and physicians.

Classification in details

  • HMO:
    • There will be coinsurance and copayments
    • Care will be received from HMO network doctors
    • Hospitalization received within HMO network
    • Facilities within HMO network to be used
    • Prior authorization must for visiting specialist
    • Specialist is to be seen
    • If out of HMO network services are availed, then full out of network fees are to be paid.
    • Few HMO networks have own prescription drug program like Medicare Part D.

This network although restrictive is found to be quite effective if facilities, hospitals and doctors can be switched.

  • PPO: In this form of Medicare Advantage Plans,
    • There is involved coinsurance and co-payments
    • Any doctor participating within the network can be visited
    • In network hospitals to be availed for hospitalization. Facilities that accept Medicare are to be used.
    • Prior authorization a must for visiting the specialist
    • Subjected to some out of network fees percentage around 30%, if out of network services are sought.
    • Few PPO networks come with own prescription drug program like Part D Medicare

Selecting PPO network involves less hassle since services can be availed across the State, however from a single hospital provide network.

  • PFFS:
    • Coinsurance and Copayments apply
    • Visit any doctor who is Medicare approved
    • Visit any hospital, Medicare approved
    • Visit any facility, Medicare approved
    • Seek out of network services
    • Prior authorization or referrals not required to visit specialist
    • Individual Prescription Drug plan is present. However, some plans do include Prescription Drugs.

Being among the top Medicare Advantage Plans, it does offer the person with great amount freedom. No network restrictions exist for doctors, hospitals and other facilities.

By understanding the different plans found under, it becomes easier for the individual to select a plan that will be deemed to be just appropriate to meet the specific needs and requirements.