Original Medicare includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). Medicare Advantage Plans are bundled plans that include Part A, Part B, and some prescription coverage, often with additional dental, vision, or hearing plans.

Original Medicare

Medicare Part A (Hospital Insurance) is offered through Original Medicare and covers hospital stays, hospice, and care in a skilled nursing facility, with some home health care coverage. Medicare Part B (Medical Insurance) is offered through Original Medicare and covers outpatient services, medical supplies, some doctors’ services, and preventive services.

Medicare Advantage Plans

Medicare Advantage (MA) Plans (often called “Part C”) are offered by private companies and insurance companies approved by Medicare. These offer Part A and Part B with additional coverage, many offering coverage for prescription drugs.

These plans cover all Medicare services, but they are paid through the company and not through Original Medicare. Many offer vision, hearing, and dental plans as part of the coverage.

The following are common plan types:

HMO Plans

Health Management Organization (HMO) Plans require that you receive care from providers in the plan’s network. If the service is not in-network, you pay the full cost. Exceptions are for emergency care, out-of-area urgent care, or out-of-area dialysis.

Most HMO plans require you to have a primary care doctor and require referrals to see specialists for most services. Many plans offer prescription drug coverage.

PPO Plans

Preferred Provider Organization (PPO) Plans have you pay more for using doctors, hospitals, and other providers that are not in-network. Many plans offer prescription drug coverage.

You can go to any doctor, hospital, or healthcare provider that is in-network and do not need a primary care doctor. You do not need a referral to see specialists, but in-network specialists will be less costly.

PFFS Plans

Private Fee-for-Service plans determine how much they pay health care providers and what you owe. You may pay more for the services of someone not in-network if the plan has a network. You only need to pay the copayments at the time of service.

You can receive treatment from any healthcare provider that agrees with the plan’s payment terms and agrees to treat you. You do not need a primary care doctor or referrals to see specialists. Some plans may not offer drug coverage.

Special Needs Plans (SNP)

Medicare SNPs are limited to people with chronic conditions, those living in institutions, or those who are dual-eligible with Medicare and Medicaid. All SNPs carry prescription drug coverage. Most SNPs require a primary care doctor and referrals for specialists.

Medicare Part D

Medicare Part D (prescription drug coverage) is offered through Medicare but is not a part of Original Medicare.

 Medicare Supplement Insurance (Medigap)

Medigap plans are offered by private companies to help pay remaining expenses not covered by Original Medicare. These expenses include copayments, coinsurance, and deductibles. These plans cannot pay the Part B deductible but offer additional service Medicare cannot. Some policies cover medical care outside of the U.S.

Medigap policies are held in addition to Medicare Part A and Part B.

For all of your Medicare Advantage questions, speak with Fidelis Insurance today. Our mission is to help you find the Medicare insurance plan you need at an affordable price.