Purchasing a Medicare Advantage Plan in Washington is another way to get your Medicare Part A, Part B, and sometimes Part D plans. A Medicare Advantage Plan is also referred to as Medicare Part C. The Advantage Plans are provided by private insurance companies that have contracted with Medicare to offer medical services at an agreed-upon price.
Most Medicare Advantage Plans cover the following services:
- Some mental health services
- Inpatient hospital stays
- Hospice care
- Doctor’s visits
- Short-term stays at skilled nursing facilities
- Some home health care
- Lab tests, blood work, and x-rays
- Durable medical equipment
- Preventative care
Some of the plans available in WA will cover additional services, such as dental care, vision and hearing care, prescription drugs, transportation to doctor’s appointments, gym memberships, and home meal delivery after an inpatient hospital stay.
Most Common Types of Medicare Advantage Plans for Washington Residents
An HMO plan, also known as a Health Maintenance Organization Plan, is a healthcare plan that provides services through a network of medical providers. If you enroll in a Medical Advantage HMO Plan, you will only receive coverage if you get care from providers who are in-network, except in the following circumstances:
- Emergency Care
- Out-of-area Dialysis Treatments
- Out-of-area Urgent Care
When you have an HMO plan, you usually have to choose a specific primary care doctor to oversee your medical choices. When you need to see a specialist, you will almost always need to obtain a referral from your primary physician. Some services don’t require a referral, like yearly mammograms.
Many of the Medicare Advantage Plans include Part D, the prescription drug plan. However, not all of them do, so make sure you look into that before deciding which plan to purchase.
Washington PPO Plans
A PPO plan, otherwise known as a Preferred Provider Organization, is another option when purchasing a Medicare Advantage Plan. PPO plans are also offered by private insurance companies that contract with Medicare. One of the issues that affects your cost of care is whether a doctor you want to see is in or out of your network. If you use an in-network doctor, it will be cheaper than if you go to a doctor who is out of the network. You will almost always be permitted to see whichever doctor or specialist that you want, but it will cost more if it’s not in-network.
Most PPO plans include prescription drug coverage. However, if you enroll in a PPO that doesn’t have a prescription drug plan, it’s important to be aware that you will not be permitted to enroll in Medicare Part D. So if you take prescription medications or think you may need them in the future, it’s a good idea to find a plan that includes prescription drug benefits.
If you’re part of a PPO plan, you do not have to choose a primary care doctor. You also aren’t required to get referrals to see specialists. However, if you see a specialist in-network, it will be cheaper than visiting an out-of-network provider.
Private Fee For Service (PFFS)
This is another common type of insurance plan that is offered by private insurance companies who also contract with Medicare to provide services at an agreed-upon rate. A PFFS has in-network providers that you can see at a lower rate than the out-of-network providers. In this plan, you will not have to choose a primary care doctor. You also don’t need referrals to see specialists or any other healthcare providers.
The Private Fee For Service plans are less common than HMOs and PPOs. Still, they might be a good option for some people because they do offer a lot of flexibility in terms of which providers you can choose.
Generally speaking, your PFFS Plan is similar in coverage to Original Medicare Part A and Part B. It will cover services such as:
- Hospital stays
- Doctor’s visits
- Ambulance rides
- Preventative care and medical screenings
- Some medical equipment
- Short-term inpatient rehabilitation
Some of these plans will offer coverage for vision care, dental care, and prescription drug coverage. If they don’t, you are permitted to purchase Medicare Part D on your own.
Healthcare providers decide if they will accept the PFFS Plan coverage for each specific service that they offer. For example, a doctor might accept the PFFS plan pricing for one type of visit but not for another, even though it’s the same doctor in the same office.
Special Needs Plan (SNP)
A special needs plan is limited to people with very specific diseases or issues. These plans tailor their benefits, healthcare providers, and drug formularies to meet the particular needs of the population they intend to serve. The Special Needs Plans are also offered by private insurance companies who contract with Medicare to provide healthcare services.
To be eligible for an SNP, you need to meet certain criteria. Depending on your specific medical issues, you will have to find a plan intended to service a person with that type of problem. For example, there is a particular plan for people who suffer from congestive heart failure.
In order to enroll in an SNP, you also have to be enrolled in Medicare parts A and B. Once you are part of the SNP plan, you will still have to pay your Medicare premiums. In some circumstances, the SNP will pay a portion of your Medicare premiums. Since the plans are offered by private insurance companies, you’ll need to check each specific plan to see if they also help with the cost of your Medicare premiums.
Special Needs Plans are required to offer Medicare Part D prescription drug coverage. Most SNP plans will also require you to choose a primary care doctor. Additionally, you must obtain referrals to see most types of specialists.
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