What to do about health care is one of the major decisions that everyone faces when getting close to retirement. A lot of people delay retirement until they reach age 65 because they don’t want to lose their employer-sponsored health plan. Even if they are financially able to retire, they will often continue to work until they are eligible for Medicare. With the uncertainty that is the state of our health care system right now, it’s hard to blame them.
But what do you do once you turn 65 years old and are eligible for Medicare? In the first part of this series on Medicare planning, I discussed the importance of timing your Medicare enrollment (Medicare Enrollment—Not As Easy As It Sounds). The second part of the series (Medicare—Which Path Is Right for You?) was a discussion on the differences between Original Medicare and Medicare Advantage. In this post, I will discuss the types of Medicare Advantage plans that are available.
As a refresher, Medicare Advantage plans are sold and administered by private insurance companies. Original Medicare is administered by the federal government. Medicare Advantage plans must provide, at a minimum, the same coverage as Original Medicare Parts A and B. The plans often include prescription drug coverage and additional coverages like vision and dental, and some come with other benefits, like a gym membership. With Original Medicare, you can visit almost any doctor in the country. With a Medicare Advantage plan, you generally get care from within the provider’s network of medical professionals. Most people choose Original Medicare, but about 30% of enrollees select Medicare Advantage.
For this post, I am going to assume you have decided that a Medicare Advantage plan would be the right path for you. If that’s the case, it’s important that you understand the types of plans you will choose from. The most common Medicare Advantage plans are health maintenance organizations (HMOs), preferred provider organizations (PPOs), and private fee-for-service (PFFS) plans. Lesser-known plans under the Medicare Advantage umbrella include special needs plans (SNPs) and medical savings account (MSA) plans. We’ll take a closer look at each type and highlight the differences.
Health maintenance organization: With this type of plan, you select a primary doctor from the insurer’s network, and that doctor manages your health care. If you need to see a specialist, you usually will need a referral from your primary doctor, and you are typically not covered for services provided outside of the network, although there are exceptions. The rules of this type of plan may be the most restrictive, but it will generally offer the lowest plan costs.
Preferred provider organization: Under a PPO, you generally can go to any doctor or hospital, but you will pay more if you use a provider outside of the insurer’s network. If you need to see a specialist, you generally won’t need a referral, but if you select a provider outside of network, you will pay more. This type of plan is more flexible, but it usually comes with a higher premium.
Private fee-for-service plan: This plan was once the fastest-growing type of Medicare Advantage plan. It was popular because you didn’t have to choose a primary care doctor and usually didn’t need a referral to see a specialist. You had to be careful with this plan, however, because not all Medicare providers accepted it. The popularity of this type of plan has declined because of some changes in the Medicare laws. It’s important to make sure you understand the details of how the plan works if you opt for it.
Special needs plan: As the name implies, this type of plan is available for Medicare enrollees who have some type of special need. The plan will offer custom benefits designed to meet the specific needs of the plan member. You could be eligible for this type of plan if you have a severe and/or chronic condition like diabetes, end-stage renal disease, chronic heart failure, or dementia. Living in a nursing home is another example of a condition that would be eligible for this type of plan.
Medicare savings account: This type of plan is not as popular as the other types of plans. It combines a high-deductible health plan with a bank account in your name. When you select this type of plan, Medicare will make deposits into your bank account that you can use to pay for medical expenses. This type of plan is really only appropriate for you if you don’t need a lot of care, because the amount deposited into your MSA is often less than the deductible.
As I wrote in the first part of this series on Medicare, getting the coverage that is best for you is not a simple process. You don’t just show up at age 65 and sign up. You need to make sure you understand your options and make the best choices based upon your individual needs. Don’t pick a plan because a friend or family member picked it. Make sure that it’s right for you.