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Medicare Coverage Options

What is a Medicare Advantage Plan?

A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, and Special Needs Plans. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage and if you want prescription drug coverage you must get it from the Medicare Advantage Plan.

What is an HMO?

  • An HMO is a Health Maintenance Organization
  • You must get your health care and services from doctors and other health care providers, or hospitals in the plan’s network (except for emergency care, out-of-area urgent care).
  • It is important that you follow the plan’s rules, like getting prior approval for a certain service when needed.
  • You may need to get a referral to see a specialist
  • If you want Medicare drug coverage, you must join an HMO plan that offers prescription drug coverage.
  • You continue to pay your Medicare Part B premium and HMO premium.
  • Are only available in select counties

What is an HMO POS?

  • An HMO POS is a Health Maintenance Organization with a Point of Service Option.
  • An HMO POS is a Medicare Advantage Plan that is a Health Maintenance Organization with a more flexible network allowing Plan Members to seek care outside of the traditional HMO network under certain situations or for certain treatment.
  • A Member will pay some additional fees for using the POS (out-of-network) option.
  • Idaho plans currently require you to use a specific hospital.
  • Are only available in select counties.
  • You continue to pay your Medicare part B premium and HMO POS premium.

What is a PPO?

Preferred Provider Organization Plans (PPOs) are among the most common and popular health plans right now for working Americans. In a PPO you:

  • Don’t need referrals to see a specialist provider out-of-network. You may need plan approval before you get certain services in and/or out-of-network.
  • Can see any doctor or provider that accepts Medicare. However, if you go to doctors, hospitals, or other providers who are not part of the plan, you may pay more.
  • You continue to pay your Medicare Part B premium and PPO premium.
  • Co-payments apply to some services and some services.

What is a Medicare SNP?

  • Medicare Special Needs Plans are specially designed for people with specialized health needs.
  • These plans must provide all Medicare Part A and Part B health care and services.
  • They also must provide Medicare prescription drug coverage (Part D).
  • These plans have special rules for enrolling.
  • Idaho’s only SNP requires you have Medicare and Medicaid and not have ESRD (end stage renal (kidney) disease).
  • Only available in select counties.
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