How Do Medicare Advantage Plans (Mcr Part - C) Work? Q & A

Can I get my health care from any doctor or hospital?

HMO Plan : No. You generally must get your care and services from doctors or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services usually for a higher cost.

PPO Plan : Yes. PPOs have network doctors and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost.



Are prescription drugs covered?

HMO Plan : In most cases, yes. Ask the plan. If you want drug coverage, you must join an HMO Plan that offers prescription drug coverage.

PPO Plan : In most cases, yes. Ask the plan. If you want drug coverage, you must join a PPO Plan that offers prescription drug coverage.



Do I need to choose a primary care doctor?

HMO Plan : In most cases, yes.

PPO Plan : No.


Do I have to get a referral to see a specialist?

HMO Plan : In most cases, yes. Yearly screening mammograms and in-network Pap tests and pelvic exams (at least every other year) don’t require a referral.

PPO Plan : No.


What else do I need to know about this type of plan?

HMO Plan :
■ If your doctor leaves the plan, your plan will notify you. You can choose another doctor in the plan.
■ If you get health care outside the plan’s network, you may have to pay the full cost.
■ It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.


PPO Plan :
■ There are two types of PPOs— Regional PPOs and Local PPOs.
■ Regional PPOs serve one of 26 regions set by Medicare.
■ Local PPOs serve the counties the PPO Plan chooses to include in its service area.