People with Medicare can obtain their medical care through original Medicare or the Medicare Advantage Program (Part C). Medicare Advantage Plans include HMO, PPO, Private Fee for Service Plans and Special Needs Plans. Of the more than 10 million individuals enrolled in Medicare Advantage Plans, almost all are enrolled in HMO’s (Health Maintenance Organizations) which have been available because the 1980’s.

To help your parents (or you) make the best decision, they have to know the way these plans work, and then decide which plan is right for them. These is a brief description of each of the plan types.

Original Medicare
If an individual elects to go with traditional fee for service Medicare, they are able to generally use any doctor or hospital that accepts Medicare assignment anywhere within the United States. However, Medicare does have deductibles, copays and cost sharing requirements that could play havoc with budgets. To help pay these additional out of pocket expenses, many individuals purchase Medigap or Medicare supplement policies.

Medicare Advantage Plans (Part C)
In the event that you prefer to go with a Medicare Advantage Plan, you actually trade your traditional Medicare benefits for these plans. Lots of the Medicare Advantage Plans are offered to eligible individuals at little if any cost other than continued payment of the Part B monthly premiums.

Medicare HMO’s (Health Maintenance Organizations)
These plans cover the exact same physician and hospital costs as traditional Medicare, but usually with lower out of pocket costs. HMO’s are appealing to Medicare eligible individuals since they often provide extra benefits like eyeglasses, hearing aids, and dental benefits which are not covered by traditional Medicare.

Individuals considering a Medicare HMO should be aware that they may only receive medical services from providers who are area of the HMO’s network of contracted providers. The HMO usually requires that an individual joining their plan select a key care physician from those that be involved in their network. This primary care physician would then lead to all medical care including referrals to a specialist and admittance to a hospital. The HMO won’t purchase unauthorized visits to specialists nor non-emergency care received away from HMO’s service area or visits to non-network physicians.

These plans are private healthcare plans like HMO’s. However, PPO’s and HMO’s do differ into two very important areas. First, Medicare PPO’s do cover eligible medical care services obtained from doctors and hospitals away from PPO network. And, second, Medicare PPO’s don’t usually require that you obtain an authorization before seeking care from a specialist.

Regional PPO’s can be found in many aspects of the country. These plans serve large geographic areas and must offer the exact same premium costs and plan benefits to all or any individuals residing in these areas. Medicare PPO’s cover the exact same types of medical expenses that traditional Medicare does. Furthermore, Medicare PPO’s commonly incorporate a prescription drug benefit. Unlike traditional Medicare, Medicare PPO’s have an annual out of pocket limit for benefits covered under Parts A and B of Medicare. The out of pocket limit caps the amount an individual can devote to covered medical expenses in a calendar year. Much like any PPO program, when an individual runs on the non-contracted provider for covered services, they will pay more out of the pocket.

These plans can be found to Medicare beneficiaries in exchange because of their traditional Medicare Benefits. PFFS don’t have a proper network of doctors and hospitals to choose from and not all doctors or hospitals are willing to provide medical services to participants in these kinds of plans. If an individual is considering enrollment, it is wise to test with their doctor and local hospitals to be sure that they will accept the plan’s payment for services before enrolling. Also, the enrollee should thoroughly understand the benefits of a fee for service plan because the fee for service plans decide how much they will purchase Medicare covered services and may charge a greater cost sharing percentage than traditional Medicare. Private fee for service plans may incorporate a prescription drug benefit. If they do not, the enrollee is free to join a Medicare standalone prescription drug plan.

These plans are private plans offering benefits to Medicare beneficiaries, including prescription drug coverage, who need additional help spending money on their medical benefits. These would include individuals who qualify for both Medicare and Medicaid (MediCal in California), those residing in long haul care facilities, and those with chronic or disabling medical conditions.

Prescription drug plans can be found to all or any Medicare eligible persons aside from medical history or income levels. Each time a person first qualifies for Medicare, their initial enrollment period begins 90 days before their 65th birthday, includes their birth month, and ends 90 days after their birth month. Otherwise, the annual open enrollment period for prescription drug plans runs from November 15th thru December 31st, with the coverage commencing on the next January 1st.

Medicare drug plans are created to reduce drug costs for enrollees and force away catastrophic drug costs. However, there is a regular cost for these plans. Along with a regular premium, the covered individual is required to pay a share of the price of the medications (or a copay) and Medicare pays area of the cost. Costs for an idea can vary depending on the medications taken and the sort of plan selected. At a minimum, the plans available must give a “standard” degree of coverage.