Understanding Medicare 

Advantage Plans

CENTERS FOR MEDICARE & MEDICAID SERVICES

This official government booklet tells you:

• How Medicare Advantage Plans are different from 

Original Medicare

• How Medicare Advantage Plans work

• How you can join a Medicare Advantage Plan
“Understanding Medicare Advantage Plans” isn’t a legal document. Official Medicare 

Program legal guidance is contained in the relevant statutes, regulations, and rulings.

The information in this booklet describes the Medicare Program at the time this booklet was 

printed. Changes may occur after printing. Visit Medicare.gov, or call 1-800-MEDICARE 

(1-800-633-4227) to get the most current information. TTY users can call 1-877-486-2048.
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Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

What are the differences between Original Medicare 

and Medicare Advantage? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

What are Medicare Advantage Plans? . . . . . . . . . . . . . . . . . . . . . . . . 9

How do Medicare Advantage Plans work? . . . . . . . . . . . . . . . . . . . . . 9

What’s covered? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

What are my costs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Who can join a Medicare Advantage Plan? . . . . . . . . . . . . . . . . . . . 12

When can I join, switch, or drop a Medicare Advantage Plan? . . . . . . . 12

How can I join a Medicare Advantage Plan? . . . . . . . . . . . . . . . . . . . 13

Can I join a Medicare Advantage Plan if I have 

End-Stage Renal Disease (ESRD)? . . . . . . . . . . . . . . . . . . . . . . . . . 14

Types of Medicare Advantage Plans . . . . . . . . . . . . . . . . . . . . . . . . 15

Compare Medicare Advantage Plans side-by-side . . . . . . . . . . . . . . . 24

What if I have a Medicare Supplement Insurance (Medigap) policy? . . . 25

Where can I get more information? . . . . . . . . . . . . . . . . . . . . . . . . 26
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When you first enroll in Medicare and each year after that, you’ll 

need to decide how you want to get 

your Medicare coverage.

You have 2 main coverage options:

• Original Medicare includes 

Medicare Part A (Hospital Insurance) 

and Part B (Medical Insurance). If 

you want prescription drug 

coverage, you’ll need to join a 

Medicare Prescription Drug Plan 

(Part D). 

• Medicare Advantage is an “all in 

one” alternative to Original 

Medicare. These “bundled” plans 

(sometimes called “Part C” or “MA 

Plans”) include Part A, Part B, and 

usually Part D. They also might 

include additional benefits that 

aren’t available in Original Medicare.

Your Medicare health plan decisions 

affect how much you pay for coverage, 

what services you get, what doctors 

you can use, and your quality of care.

Learning about your Medicare coverage 

choices, getting help from people you 

trust, and comparing different plans 

can help you understand all the options 

available to you. 

Introduction
5

What are the differences between Original Medicare 

and Medicare Advantage?

Original Medicare

• Original Medicare includes Medicare 

Part A (Hospital Insurance) and Part B 

(Medical Insurance).

• If you want drug coverage, you can join a 

separate Part D plan.

• To help pay your out-of-pocket costs in 

Original Medicare (like your deductible 

and 20% coinsurance), you can also shop 

for and buy supplemental coverage.

Part A

Part B

 You can add:

Part D

 You can also add:

Supplemental 

coverage

(Some examples include

coverage from a Medicare

Supplement Insurance

(Medigap) policy, or coverage

from a former employer or

union.)

Medicare Advantage

(also known as Part C)

• Medicare Advantage is an “all in one” 

alternative to Original Medicare. These 

“bundled” plans include Part A, Part B, 

and usually Part D.

• Some plans may have lower out-of- pocket 

costs than Original Medicare.

• Some plans offer extra benefits that 

Original Medicare doesn’t cover— like 

vision, hearing, or dental.

Part A

Part B

 Most plans include:

Part D

 Some plans also include:

Lower out-of-pocket-costs

Extra benefits
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Original Medicare vs. Medicare Advantage

Doctor and hospital choice

Original Medicare Medicare Advantage

You can go to any doctor that accepts 

Medicare.

In most cases, you’ll need to use doctors who are 

in the plan’s network (for non-emergency or nonurgent care). It may cost you more if you go to a 

doctor outside of the plan’s network. Ask your doctors 

if they participate in any Medicare Advantage Plans.

In most cases you don’t need a referral to 

see a specialist.

You may need to get a referral to see a specialist.

Costs

Original Medicare Medicare Advantage

Most people don’t pay a premium (monthly 

payment) for Part A. 

For hospital services, you pay a deductible 

and coinsurance. 

Out-of-pocket costs vary—some plans have low or 

no out-of-pocket costs. 

Medicare Advantage Plans can’t charge more 

than Original Medicare for certain services, like 

chemotherapy, dialysis, and skilled nursing facility care.

You pay a premium for Part B (The 2019 

Part B premium is $135.50) If you choose 

to buy prescription drug coverage, you’ll pay 

that premium separately.

You may pay a premium for the plan (most include 

prescription drug coverage) and a premium for 

Part B. Some plans have a $0 premium or will help 

pay all or part of your Part B premium.

For Part B-covered services, you usually pay 

20% of the Medicare-approved amount

after you meet your deductible.

You pay your plan’s deductibles and copayments 

(usually a fixed amount, like $10 or $20 when you 

see a doctor). You could pay more for medical care if 

you don’t follow your plan’s rules, like using the plan’s 

network providers.

There’s no yearly limit on what you pay 

out-of-pocket.

Plans have a yearly limit on what you pay 

out-of-pocket for Medicare Part A and B covered 

services. Once you reach your plan’s limit, you’ll pay 

nothing for Part A and Part B covered services for the 

rest of the year.

You can buy supplemental coverage to 

help pay your out-of-pocket costs (like your 

deductible and 20% coinsurance).

You can’t buy or use separate supplemental 

coverage—but some plans have lower out-of-pocket 

costs than Original Medicare.
7

Original Medicare vs. Medicare Advantage

(continued)

Coverage

Original Medicare Medicare Advantage

Original Medicare covers medical services 

and supplies in hospitals, doctors’ offices, 

and other health care settings.

Plans must cover all of the services that Original Medicare 

covers (with a few exceptions, like hospice or some clinical 

trial costs). Some plans offer extra benefits that Original 

Medicare doesn’t cover—like vision, hearing, dental, and/or 

health and wellness programs.

You can join a separate Medicare 

Prescription Drug Plan to get drug coverage.

Prescription drug coverage is included in most plans.

In most cases, you don’t have to get a 

service or supply approved ahead of time 

for it to be covered.

In some cases, you have to get a service or supply 

approved ahead of time for it to be covered by the plan.

Travel

Original Medicare Medicare Advantage

Original Medicare covers care when you’re 

traveling in any of the 50 U.S. states, the District 

of Columbia, Puerto Rico, and any other U.S. 

territory. 

In general, health care you get while traveling 

outside of the U.S. isn’t covered. 

In some rare cases, Medicare may pay for urgent 

or emergency care you get in a foreign country. 

For more information about coverage when 

traveling, visit Medicare.gov/coverage/travelwhen-you-need-health-care-outside-the-us.

Medicare Advantage Plans cover care when you’re 

traveling in any of the 50 U.S. states, the District of 

Columbia, Puerto Rico, and any other U.S. territory. 

In general, health care you get while traveling outside of 

the U.S. isn’t covered. 

In some rare cases, Medicare may pay for urgent or 

emergency care you get in a foreign country. For more 

information about coverage when traveling, visit 

Medicare.gov/coverage/travel-when-you-need-healthcare-outside-the-us.
8
9

What are Medicare Advantage Plans?

Medicare Advantage Plans are another way to get your Medicare coverage. Medicare 

Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicareapproved private companies that must follow rules set by Medicare. If you join a 

Medicare Advantage Plan, you’ll still have Medicare but you’ll get your Medicare 

Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from 

the Medicare Advantage Plan, not Original Medicare. 

How do Medicare Advantage Plans work?

When you join a Medicare Advantage Plan, Medicare pays a fixed amount for your 

coverage each month to the company offering that plan. These companies must 

follow Medicare’s coverage rules. Medicare Advantage Plans have yearly contracts 

with Medicare. The plan will notify you about any changes before the start of the 

next enrollment year. 

If you join a Medicare Advantage Plan, you’ll have all of the same rights and 

protections that you would have under Original Medicare.

What’s covered? 

Medicare Advantage Plans cover all Medicare Part A and Part B services. However, 

if you’re in a Medicare Advantage Plan, Original Medicare will still cover the cost 

for hospice care, some new Medicare benefits, and some costs for clinical research 

studies. In all types of Medicare Advantage Plans, you’re always covered for 

emergency and urgent care. 

Some Medicare Advantage Plans offer extra coverage, for things like vision, hearing, 

dental, and other health and wellness programs. Plans have a yearly limit on what 

you pay out-of-pocket for Medicare Part A and B covered services. Once you reach 

your plan’s limit, you’ll pay nothing for Part A and Part B covered services for the 

rest of the year. 

Medicare Advantage Plans

Overview
10

What’s covered? (continued) 

Prescription drug coverage

Most Medicare Advantage Plans include Medicare prescription drug coverage 

(Part D). In certain types of plans that don’t include drug coverage (like Medical 

Savings Account plans and some Private-Fee-for-Service plans), you can join a separate 

Medicare Prescription Drug Plan. You can also add prescription drug coverage in one 

of the following ways:

• You can switch during certain times to another Medicare Advantage Plan or 

other Medicare health plan in your area that offers Medicare prescription drug 

coverage. 

• You can switch to Original Medicare, and add a Medicare Prescription Drug Plan.

Note: If you’re in a plan that doesn’t offer drug coverage, and you don’t have a 

Medicare Prescription Drug Plan, you may have to pay a late enrollment penalty 

if you decide to join a Medicare Prescription Drug Plan or get a plan with drug 

coverage later. Visit Medicare.gov/drug-coverage-part-d/costs-for-medicaredrug-coverage/part-d-late-enrollment-penalty to learn more about the Part D late 

enrollment penalty.

What are my costs?

Each year, plans set the amounts they charge for premiums, deductibles, and services. 

The plan (rather than Medicare) decides how much you pay for the covered services 

you get. What you pay the plan may change only once a year, on January 1. 

The standard Part B premium amount in 2019 is $135.50 (or higher depending on your 

income). Some people with Social Security benefits pay less ($130 on average).

When calculating your out-of-pocket costs in a Medicare Advantage Plan, in 

addition to your premium, deductible, copayments, and coinsurance, you should 

also consider: 

• The type of health care services you need and how often you get them.

• Whether you go to a doctor or supplier who accepts assignment. Assignment 

means that your doctor, provider, or supplier agrees (or is required by law) to 

accept the Medicare-approved amount as full payment for covered services.

• Whether the plan offers extra benefits that require an extra premium. 

• Whether you have Medicaid or get help from your state with health care costs.
11

What are my costs? (continued)

What’s the difference between a deductible, coinsurance, and a copayment?

Deductible—The amount you must pay for health care or prescriptions before Original 

Medicare, your prescription drug plan, or your other insurance begins to pay. 

Coinsurance—An amount you may be required to pay as your share of the cost 

for services after you pay any deductibles. Coinsurance is usually a percentage (for 

example, 20%).

Copayment—An amount you may be required to pay as your share of the cost 

for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or 

prescription drug. A copayment is usually a set amount, rather than a percentage. 

For example, you might pay $10 or $20 for a doctor’s visit or prescription drug.

More cost details from each plan

If you join a Medicare Advantage Plan, review these notices you get from your plan 

each year:

• “Annual Notice of Change” (ANOC). Includes any changes in coverage, costs, 

service area, and more that will be effective starting in January. Your plan will 

send you a printed copy by September 30.

• “Evidence of Coverage” (EOC). Gives you details about what the plan covers, 

how much you pay, and more. Your plan will send you a notice (or printed 

copy) by October 15, which will include information on how to access the EOC 

electronically or request a printed copy.

Organization determinations

In a Medicare Advantage Plan, you (or a provider acting on your behalf) can request 

to see if an item or service will be covered by the plan, before you get it. Sometimes 

you must do this for the service to be covered. This is called an “organization 

determination.” If your plan denies coverage for the item or service, the plan must tell 

you in writing.

If a network provider didn’t get an organization determination before providing an 

item or service, you don’t have to pay more than the plan’s usual cost sharing for a 

service or supply if either of these is true:

• The provider gave you or referred you for services or supplies that you reasonably 

thought would be covered.

• The provider referred you to an out-of-network provider for plan-covered services.
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Who can join a Medicare Advantage Plan?

You can join a Medicare Advantage Plan if:

• You have Part A and Part B.

• You live in the plan’s service area.

• You’re a U.S. citizen, U.S. national, or lawfully present in the U.S.

• You don’t have End-Stage Renal Disease (ESRD), except as explained on page 14.

What if I have other coverage?

Talk to your employer, union, or other benefits administrator about their rules 

before you join a Medicare Advantage Plan. In some cases, if you join a Medicare 

Advantage Plan, you may still be able to use your employer or union coverage along 

with your Medicare Advantage Plan. In other cases, joining a Medicare Advantage 

Plan might cause you to lose your employer or union coverage for yourself, your 

spouse, and dependents.

When can I join, switch, or drop a Medicare Advantage 

Plan?

You can only join, switch, or drop a Medicare Advantage Plan during the 

enrollment periods below: 

• Initial Enrollment Period—When you first become eligible for Medicare, you 

can sign up during your Initial Enrollment Period. This is the 7-month period 

that begins 3 months before the month you turn 65, includes the month you turn 

65, and ends 3 months after the month you turn 65.

If you sign up during the first 3 months of your Initial Enrollment Period, in 

most cases, your coverage starts the first day of your birthday month. However, 

if your birthday is on the first day of the month, your coverage will start the first 

day of the prior month.

If you enroll the month you turn 65 or during the last 3 months of your Initial 

Enrollment Period, your start date for coverage will be delayed.

• General Enrollment Period—If you have Part A coverage and you get Part B for 

the first time during the General Enrollment Period (between January 1—

March 31 each year), you can also join a Medicare Advantage Plan at that time. 

Your coverage will start July 1.

• Open Enrollment Period—Between October 15—December 7, anyone with 

Medicare can join, switch, or drop a Medicare Advantage Plan. Your coverage 

will begin on January 1, as long as the plan gets your request by December 7.

Note: In certain 

situations (like if 

you move), you 

may be able to 

join, switch, or 

drop a plan at 

other times.
13

When can I join, switch, or drop a Medicare Advantage 

Plan? (continued)

Can I make changes to my coverage after December 7?

Starting in 2019, between January 1–March 31 each year, you can make these 

changes during the Medicare Advantage Open Enrollment Period:

• If you’re in a Medicare Advantage Plan (with or without drug coverage), you can 

switch to another Medicare Advantage Plan (with or without drug coverage).

• You can disenroll from your Medicare Advantage Plan and return to Original 

Medicare, but you may not be able to buy a Medigap policy. If you choose to return 

to Original Medicare, you’ll be able to join a Medicare Prescription Drug Plan.

• If you enrolled in a Medicare Advantage Plan during your Initial Enrollment 

Period, you can change to another Medicare Advantage Plan (with or without drug 

coverage) or go back to Original Medicare (with or without drug coverage) within 

the first 3 months you have Medicare. 

During the Medicare Advantage Open Enrollment Period, you can’t:

• Switch from Original Medicare to a Medicare Advantage Plan.

• Join a Medicare Prescription Drug Plan if you’re in Original Medicare.

• Switch from one Medicare Prescription Drug Plan to another if you’re in Original 

Medicare.

You can only make one change during this period, and any changes you make will be 

effective the first of the month after the plan gets your request.

Always review the materials your plan sends you (like the “Annual Notice of 

Change”), and make sure your plan will still meet your needs for the following year.

What if I have a pre-existing condition?

You can join a Medicare Advantage Plan even if you have a pre-existing condition, 

except for End-Stage Renal Disease (ESRD), for which there are special rules. See 

“Can I join A Medicare Advantage Plan if I have End-Stage Renal Disease (ESRD)?” 

on page 14.

How can I join a Medicare Advantage Plan?

Not all Medicare Advantage Plans work the same way. Before you join, you 

can find and compare Medicare health plans in your area by visiting 

Medicare.gov/find-a-plan. Once you understand the plan’s rules and costs, use 

one of these ways to join:

• Use Medicare’s Plan Finder at Medicare.gov/find-a-plan. You can search by ZIP 

Code or use your MyMedicare.gov account for information tailored just for you.
14

How can I join a Medicare Advantage Plan? (continued)

• Visit the plan’s website to see if you can join online.

• Fill out a paper enrollment form. Contact the plan to get an enrollment form, fill it 

out, and return it to the plan. All plans must offer this option.

• Call the plan you want to join. Visit Medicare.gov/find-a-plan and put in the ZIP 

Code (under General Search) to get your plan’s contact information. You can also 

search by plan name at Medicare.gov/find-a-plan/questions/search-by-plan-nameor-plan-id.aspx. 

• Call us at 1-800-MEDICARE (1-800-633-4227). TTY users can call 

1-877-486-2048.

When you join a Medicare Advantage Plan, you’ll have to provide this information 

from your Medicare card:

• Your Medicare Number

• The date your Part A and/or Part B coverage started. 

Remember, when you enroll in a Medicare Advantage Plan, in most cases, you must 

use the card from your Medicare Advantage Plan to get your Medicare-covered 

services. For some services, you may be asked to show your red, white, and blue 

Medicare card.

Can I join a Medicare Advantage Plan if I have 

End-Stage Renal Disease (ESRD)?

If you have End-Stage Renal Disease (ESRD), you can only join a Medicare Advantage 

Plan in certain situations:

• If you’re already in a Medicare Advantage Plan when you develop ESRD, you can stay 

in your plan or you may be able to join another Medicare Advantage Plan offered by 

the same company.

• If you’re in a Medicare Advantage Plan, and the plan leaves Medicare or no longer 

provides coverage in your area, you have a one-time right to join another Medicare 

Advantage Plan.

• If you have an employer or union health plan or other health coverage through a 

company that offers one or more Medicare Advantage Plan(s), you may be able to 

join one of that company’s Medicare Advantage Plans.

• If you’ve had a successful kidney transplant, you may be able to join a Medicare 

Advantage Plan.

• You may be able to join a Medicare Special Needs Plan (SNP) that covers people with 

ESRD if one is available in your area.

For more information, visit Medicare.gov/Publications to view the booklet “Medicare 

Coverage of Kidney Dialysis & Kidney Transplant Services.” 
15

Types of Medicare Advantage Plans

There are different types of Medicare Advantage Plans:

• Health Maintenance Organization (HMO) plans: See pages 15–16.

• Preferred Provider Organization (PPO) plans: See page 17.

• Private Fee-for-Service (PFFS) plans: See pages 18–19.

• Special Needs Plans (SNPs): See pages 20–21.

• Medical Savings Account (MSA) plans: See pages 22–23.

The area where you live might have all, some, or none of these types available. 

In addition, there might be multiple plans available in your area within the same 

type, if private companies choose to offer them. To see Medicare Advantage Plans 

available to you, visit Medicare.gov/find-a-plan. 

Health Maintenance Organization (HMO) plans

A Health Maintenance Organization (HMO) plan is a type of Medicare Advantage 

Plan that usually provides health care coverage from doctors, specialists, or 

hospitals in the plan’s network, except in an emergency or urgent care situation. 

A network is a group of doctors, hospitals, and medical facilities that contract 

with a plan to provide services. Most HMOs also require you to get a referral from 

your primary care doctor for specialist care, so that your care is coordinated.

Can I get my health care from any doctor, other health care provider, or 

hospital?

In HMO Plans, you generally must get your care and services from doctors or 

hospitals in the plan’s network, (except for emergency care, out-of-area urgent 

care, or out-of-area dialysis).

Types of Medicare 

Advantage Plans
16

Types of Medicare Advantage Plans (continued)

Health Maintenance Organization (HMO) plans (continued)

You’ll pay less if you see doctors and use medical facilities that are in your plan’s 

network. 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. In most cases, you need to choose a 

primary care doctor. Certain services, like yearly screening mammograms, don’t 

require a referral. If your doctor or other health care provider leaves the plan’s 

network, your plan will notify you. You may choose another doctor in the plan’s 

network. 

HMO Point-of-Service (HMOPOS) plans are HMO plans that may allow you to 

get some services out-of-network for a higher copayment or coinsurance. It’s 

important that you follow the plan’s rules, like getting prior approval for a certain 

service when needed.

The POS portion of the plan has a separate deductible. The care you get 

in-network through the HMO has a different deductible than care you get 

out-of-network through the POS. You must reach the two deductibles separately.

Are prescription drugs covered?

In most cases, prescription drugs are covered in Medicare HMO plans. If you 

want drug coverage, you must join an HMO plan that includes prescription drug 

coverage. If you join an HMO that doesn’t include prescription drug coverage, 

you can’t get a separate Medicare Prescription Drug Plan (Part D). 
17

Types of Medicare Advantage Plans (continued)

Preferred Provider Organization (PPO) plans

A Preferred Provider Organization (PPO) plan is a Medicare Advantage Plan that 

has a network of primary care doctors, specialists, and hospitals that you may go 

to. You also can choose to go to any doctor, specialist, or hospital not on the plan’s 

(out-of-network) list, but it will usually cost more. Because certain providers are 

“preferred” (as the name suggests), you can save money by using them. 

Can I get my health care from any doctor, other health care provider, or 

hospital?

In most cases, you can get your health care from any doctor, other health care 

provider, or hospital in PPO Plans. 

PPO Plans have network doctors, other health care providers, and hospitals. Each 

plan gives you the choice to go to doctors, specialists, or hospitals that aren’t on the 

plan’s list, but it will usually cost less if you get your care from a network provider.

You can get care from specialists without a referral or prior authorization from 

another doctor. If you use plan specialists, your costs for covered services will 

usually be lower than if you use non-plan specialists.

Are prescription drugs covered?

In most cases, prescription drugs are covered in PPO plans. If you want Medicare 

drug coverage, you must join a PPO plan that includes prescription drug coverage. 

If you join a PPO plan that doesn’t include prescription drug coverage, you can’t 

join a separate Medicare Prescription Drug Plan (Part D).
18

Types of Medicare Advantage Plans (continued)

Private Fee-for-Service (PFFS) plans 

A Private Fee-for-Service (PFFS) plan is a Medicare Advantage Plan offered by a 

private health insurance company. A PFFS plan isn’t the same as Original Medicare 

or a Medicare Supplement (Medigap) policy.

Insurance companies that offer PFFS plans can decide that a plan will be available 

to everyone with Medicare in a state, or be available only in certain counties. 

Insurance companies may also offer more than one plan in an area, with different 

benefits and costs. Each year, insurance companies offering PFFS plans can decide 

whether to offer such a plan in a given area. 

Can I get my health care from any doctor, other health care provider, or 

hospital?

You can go to any Medicare-approved provider like a doctor, other health care 

provider, or hospital that accepts the plan’s payment terms and agrees to treat you. 

If you join a PFFS plan that has a network, you can also see any of the network 

providers who have agreed to always treat plan members. You can also choose an 

out-of-network doctor, hospital, or other provider, who accepts the plan’s terms, 

but you may pay more.

Before you get any services, ask your doctor or hospital if they can contact the 

plan for payment information and accept the plan’s payment terms. If you need 

emergency care, it’s covered whether the provider accepts the plan’s payment terms 

or not.

If your provider agrees to the plan’s terms and conditions of payment

The provider must follow the plan’s terms and conditions for payment, and bill 

the plan for the services they provide for you. However, the provider can decide at 

every visit whether or not to accept the plan and agree to treat you.

If your provider doesn’t agree to the plan’s terms and conditions of 

payment

The provider shouldn’t provide services to you except in emergencies, and you’ll 

need to find another provider that will accept the PFFS plan.

If the provider chooses to treat you, then they can’t bill you. They must bill the plan 

for your covered health care services. You’re only required to pay the copayment 

or coinsurance the plan allows for the types of services you get at the time of the 

service. You may have to pay an additional amount (up to 15% more) if the plan 

allows providers to “balance bill” (when a provider bills you for the difference 

between the provider’s charge and the allowed amount). 
19

Types of Medicare Advantage Plans (continued)

Private Fee-for-Service (PFFS) plans (continued)

Note: If your PFFS plan has a network of providers for some or all categories of 

services, you can still see providers who aren’t part of the plan’s network. As long 

as providers accept the plan’s payment terms, you can get your services from them, 

but you may pay more if they’re out of the network. 

Are prescription drugs covered?

Prescription drugs may be covered in a PFFS plan. If you want Medicare 

prescription drug coverage, and it’s offered by the plan, you must get your 

Medicare prescription drug coverage from that plan. 

If the PFFS plan doesn’t offer drug coverage, you can join a separate Medicare 

Prescription Drug Plan (Part D) to get coverage. 
20

Types of Medicare Advantage Plans (continued)

Special Needs Plans (SNP)

A Special Needs Plan (SNP) provides benefits and services to people with specific 

diseases or health care needs. SNPs tailor their benefits, provider choices, and 

drug formularies to best meet the specific needs of the groups they serve.

SNPs cover the same Medicare services that all Medicare Advantage Plans cover. 

Medicare SNPs might also cover extra services tailored to the special groups 

they serve. For example, if you have a severe or chronic condition, like cancer or 

chronic heart failure and you require a hospital stay, an SNP may cover extra days 

in the hospital. 

You may qualify for an SNP if you live in the plan’s service area and meet one of 

these requirements: 

– You have a chronic illness like one or more of the conditions below (also 

called a Chronic condition SNP or C-SNP):

• Chronic alcohol and other dependence

• Autoimmune disorders

• Cancer (excluding pre-cancer conditions)

• Cardiovascular disorders

• Chronic heart failure

• Dementia

• Diabetes mellitus

• End-stage liver disease

• End-Stage Renal Disease (ESRD) requiring dialysis (any mode of 

dialysis)

• Severe hematologic disorders

• HIV/AIDS

• Chronic lung disorders

• Chronic and disabling mental health conditions

• Neurologic disorders

• Stroke
21

Types of Medicare Advantage Plans (continued) 

Special Needs Plans (SNP) (continued)

– You live in an institution (like a nursing home), or need nursing care at home 

(also called an Institutional SNP or I-SNP).

– You have both Medicare and Medicaid (also called a Dual Eligible SNP 

or D-SNP).

Each SNP limits its membership to people in one of these groups, or a subset of 

one of these groups. You can only stay enrolled in an SNP if you continue to meet 

the special conditions that the plan serves.

Can I get my health care from any doctor, other health care provider, or 

hospital?

You generally must get your care and services from doctors, other health care 

providers, or hospitals in the plan’s network (except for emergency care, 

out-of-area urgent care, or out-of-area dialysis).

In most cases, SNPs may require you to have a primary care doctor, or the plan 

may require you to have a care coordinator to help with your health care. A 

care coordinator is someone who helps make sure people get the right care and 

information. For example, an SNP for people with diabetes might use a care 

coordinator to help members monitor their blood sugar and follow their diet.

SNPs typically have specialists in the diseases or conditions that affect their 

members. Generally, you must get your care and services from doctors or hospitals 

in the plan’s network, except: 

• When you need emergency or urgent care, like care you get for a sudden illness 

or injury that needs medical care right away

• If you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis

Are prescription drugs covered?

All SNPs must provide Medicare prescription drug coverage (Part D).
22

Types of Medicare Advantage Plans (continued)

Medical Savings Account plans

Medical Savings Account (MSA) plans combine a high-deductible insurance plan with 

a medical savings account that you can use to pay for your health care costs.

1. High-deductible health plan: The first part of an MSA plan is a special type of 

high-deductible Medicare Advantage Plan. The plan will only begin to cover your 

costs once you meet a high yearly deductible, which varies by plan.

2. Medical Savings Account (MSA): The second part of an MSA plan is a special 

type of savings account. The MSA plan deposits money into your account. You can 

choose to use money from this savings account to pay your health care costs before 

you meet the deductible.

In addition to the Medicare Part A and Part B services that all MSA plans must 

cover, some MSA plans may cover extra benefits for an extra cost, like:

• Dental

• Vision

• Long-term care not covered by Medicare

Can I get my health care from any doctor, other health care provider, or 

hospital?

With an MSA plan, you can choose your health care services and providers.

Are prescription drugs covered?

If you join an MSA plan, you’ll need to join a Medicare Prescription Drug Plan (Part 

D) to get drug coverage.

However, if you join an MSA plan and already have a Medigap policy with drug 

coverage (some policies sold before January 1, 2006 had drug coverage), you can 

continue to use this coverage to pay for some of your drugs. 

Once you decide which MSA plan you want, you’ll need to contact the plan for 

enrollment information and to join. When you get the enrollment form, fill it out 

and mail it to the plan, or give it to a plan representative. The plan will tell you 

how to set up your account with a bank that the plan selects. You must set up this 

account before your enrollment can be processed. After you get a letter from the 

plan telling you when your coverage begins: 

1. Medicare gives the plan an amount of money each year for your health care.

 
23

Types of Medicare Advantage Plans (continued)

Medical Savings Account plans (continued)

2. The plan deposits money into your account on your behalf. You can’t deposit your 

own money.

3. You can use the money in your account to pay your health care costs, including 

health care costs that aren’t covered by Medicare. When you use account money 

for Medicare-covered Part A and Part B services, it counts towards your plan’s 

deductible.

4. If you use all of the money in your account and you have additional health care costs, 

you’ll have to pay for your Medicare-covered services out-of-pocket until you reach 

your plan’s deductible.

5. During the time you’re paying out-of-pocket for services before the deductible is 

met, doctors and other providers can’t charge you more than the Medicare-approved 

amount.

6. After you reach your deductible, your plan will cover your Medicare-covered 

services. 

7. Money left in your account at the end of the year stays in the account, and may be 

used for health care costs in future years. If you stay with the same MSA plan the 

following year, the new deposit will be added to any leftover amount.

MSA plans and your taxes

If you use funds from your account, you must include IRS Form 8853 with 

information on how you used your account money when you file taxes. 

Each year, you should get a 1099-SA form from your bank that includes all of the 

withdrawals from your account. You’ll need to show that you’ve had Qualified 

Medical Expenses in at least this amount, or you may have to pay taxes and 

additional penalties.

For a list of services and products that count as Qualified Medical Expenses and 

for other tax information, visit irs.gov/forms-pubs/about-publication-969 to get 

a free copy of the IRS publication #969 for the year that you’re filing to get more 

information about tax form 8853.

Contact your personal financial advisor (if you have one) for counseling and advice 

on how choosing an MSA plan could affect your financial situation. 
24

Compare Medicare Advantage Plans side-by-side

The chart below shows basic information about each type of Medicare Advantage Plan.

HMO PPO PFFS SNP MSA

Premium

Do I have to 

pay a monthly 

premium?

Yes

May charge a 

premium in 

addition to Part B 

premium.

Yes

May charge a 

premium in 

addition to Part B 

premium.

Yes

May charge a 

premium in addition 

to Part B premium.

Yes

May charge a 

premium in 

addition to Part B 

premium.

No

You won’t have 

to pay a monthly 

premium, but 

you’ll continue to 

pay the monthly 

Part B premium.

Drugs

Does the plan 

offer Medicare 

prescription 

drug coverage?

Usually

If you join a HMO 

that doesn’t offer 

drug coverage, 

you can’t get a 

separate Medicare 

Prescription Drug 

Plan.

Usually

If you join a PPO 

plan that doesn’t 

offer drug coverage, 

you can’t get a 

separate Medicare 

Prescription Drug 

Plan.

Usually

If you join a PFFS 

plan that doesn’t offer 

drug coverage, you 

can get a Medicare 

Prescription Drug 

Plan.

Yes

All SNPs must 

provide Medicare 

prescription drug 

coverage.

No

You’ll have to 

join a Medicare 

Prescription 

Drug Plan. If 

you already 

have a Medigap 

policy with drug 

coverage, you can 

continue to use 

this coverage to 

pay for some of 

your drugs.

Providers

Can I use 

any doctor 

or hospital 

that accepts 

Medicare 

for covered 

services?

Maybe

You generally 

must get your 

care and services 

from doctors, 

other health care 

providers, or 

hospitals in the 

plan’s network 

(except emergency 

care or out-of-area 

dialysis).

In an HMOPOS 

you may be able to 

get some services 

out-of-network for 

a higher copayment 

or coinsurance.

Yes

Each plan has a 

network of doctors, 

hospitals, and other 

providers that you 

may go to. Your 

costs may be higher 

if you use providers 

outside the plan.

Yes

You can go to any 

Medicare-approved 

doctor, other health 

care provider, or 

hospital that accepts 

the plan’s payment 

terms and agrees to 

treat you. If the plan 

has a network, you 

can use any of the 

network providers (if 

you go to an out-ofnetwork provider 

that accepts the plan’s 

terms, you may pay 

more).

No

Generally, you 

must get your 

care and services 

from doctors or 

hospitals in the 

SNP’s network 

(except emergency 

or urgent care, or if 

you have End-Stage 

Renal Disease and 

need out-of-area 

dialysis).

Yes

You have flexibility 

in choosing 

your health care 

services and 

providers.

Referral

Do I need a 

referral from my 

doctor to see a 

specialist?

Yes No Maybe

Plans may vary.

Maybe No
25

What if I have a Medicare Supplement Insurance 

(Medigap) policy? 

Medigap policies can’t work with Medicare Advantage Plans. If you have a 

Medigap policy and join a Medicare Advantage Plan, you may want to drop 

your Medigap policy. Your Medigap policy can’t be used to pay your Medicare 

Advantage Plan copayments, deductibles, and premiums.

If you want to cancel your Medigap policy, contact the insurance company that 

offers your policy. If you cancel the Medigap policy, you might not be able to 

get the same, or in some cases, any Medigap policy back. If you have a Medicare 

Advantage Plan already, it’s illegal for anyone to sell you a Medigap policy unless 

you’re switching back to Original Medicare. 

If you join a Medicare Advantage Plan for the first time and decide the plan isn’t 

right for you, you’ll have a special right (called a “trial right”) to buy a Medigap 

policy. You have this right if you return to Original Medicare within 12 months of 

joining.

• If you had a Medigap policy before you joined, you may be able to get the same 

policy back if the company still sells it. If it isn’t available, you can buy another 

Medigap policy.

• The Medigap policy can no longer have prescription drug coverage even if you 

had it before, but you may be able to join a Medicare Prescription Drug Plan.

• If you joined a Medicare Advantage Plan when you were first eligible for 

Medicare, you can choose from any Medigap policy available in your state.
26

Where can I get more information? 

• Medicare Plan Finder

The Medicare Plan Finder is an online resource to help you view and compare 

all available drug and health plan choices. To find and compare available plans in 

your area, visit the Medicare Plan Finder at Medicare.gov/find-a-plan.

You can search by ZIP code or use your MyMedicare.gov account for information 

tailored just for you. 

• 1-800-MEDICARE

The Medicare Call Center can help you with specific questions about billing, 

claims, medical records, expenses, and more. Call 1-800-MEDICARE 

(1-800-633-4227). TTY users can call 1-877-486-2048.

• SHIPs (State Health Insurance Assistance Programs)

SHIPs are state programs that get money from the federal government to 

give local health insurance counseling to people with Medicare at no cost to 

you. SHIPs aren’t connected to any insurance company or health plan. SHIP 

volunteers can help you with these Medicare questions or concerns:

– Your Medicare rights

– Billing problems

– Complaints about your medical care or treatment

– Plan choices

– How Medicare works with other insurance

– Finding help paying for health care costs

You can find the phone number for your state’s SHIP by visiting shiptacenter.org

or by calling 1-800-MEDICARE (1-800-633-4227). TTY users can call 

1-877-486-2048.

• Medicare Advantage Plans

Contact the plans you’re interested in for detailed information about costs and 

coverage.
27

Notice of Accessible Communications

To help ensure people with disabilities have an equal opportunity to participate in 

our services, activities, programs, and other benefits, we provide communications in 

accessible formats. The Centers for Medicare & Medicaid Services (CMS) provides 

auxiliary aids and services to help us better communicate with people with disabilities. 

Auxiliary aids include materials in Braille, audio/data CD or other accessible formats.

Note: You can get the “Medicare & You” handbook electronically in standard print, 

large print, or as an eBook.

For general Medicare inquiries and Medicare publications, call us at 1-800-MEDICARE 

(1-800-633-4227). TTY: 1-877-486-2048.

For all other CMS publications and documents in accessible formats, you can contact 

our Customer Accessibility Resource Staff:

Call 1-844-ALT-FORM (1-844-258-3676). TTY: 1-844-716-3676.

• Send a fax to 1-844-530-3676.

• Send an email to altformatrequest@cms.hhs.gov.

• Send a letter to:

Centers for Medicare & Medicaid Services

Offices of Hearings and Inquiries (OHI)

 7500 Security Boulevard, Mail Stop S1-13-25

Baltimore, MD 21244-1850

 Attn: Customer Accessibility Resource Staff

You can also contact the Customer Accessibility Resource staff:

• To inquire about a request for accessible formats.

• To submit concerns and issues about accessible communications, including the 

quality and timeliness of your request.

Note: Your request for a CMS publication or document should include:

• Your name, phone number, and the mailing address where we should send the 

publications or documents.

• The publication title and CMS Product No., if known.

• The format you need, like Braille, large print, or data/audio CD.

Note: If you’re enrolled in a Medicare Advantage or Medicare Prescription Drug Plan, 

you can contact your plan to request their documents in an accessible format.
28

Nondiscrimination Notice

CMS doesn’t exclude, deny benefits to, or otherwise discriminate against any person 

on the basis of race, color, national origin, disability, sex, or age in admission to, 

participation in, or receipt of the services and benefits under any of its programs and 

activities, whether carried out by CMS directly or through a contractor or any other 

entity with which CMS arranges to carry out its programs and activities.

How to file a complaint

If you believe you’ve been subjected to discrimination in a CMS program or activity, 

there are 3 ways to file a complaint with the U.S. Department of Health and Human 

Services, Office for Civil Rights:

1. Online at hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html.

2. By phone: Call 1-800-368-1019. TDD user can call 1-800-537-7697.

3. In writing: Send information about your complaint to:

Office for Civil Rights

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

Paid for by the Department of Health & Human Services.
29

Notes
30

Notes
31
U.S. DEPARTMENT OF 

HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services 

7500 Security Boulevard

Baltimore, Maryland 21244-1850

Official Business 

Penalty for Private Use, $300 

CMS Product No. 12026

October 2018

Understanding Medicare Advantage Plans

■ Medicare.gov 

■ 1-800-MEDICARE (1-800-633-4227) 

■ TTY: 1-877-486-2048 

¿ Necesita usted una copia en español? 

Llame GRATIS al 1-800-MEDICARE (1-800-633-4227).