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Frequently Asked Questions on MAPD

Questions you may have about HMOs

Question:	Answer:
Do these plans charge a monthly premium?	Yes. These plans usually charge a premium, in addition to the monthly Part B (Medical Insurance) premium.
Do these plans offer Medicare drug coverage (Part D)?	Usually. Prescription drugs are covered in most HMOs. Check with the plan you’re interested in. HMOs & drug coverage If you want prescription drug coverage, you have to join an HMO that offers it. If you join an HMO plan that doesn't offer drug coverage, you can't* join a separate Medicare drug plan.*
Can I use any doctor or hospital that accepts Medicare for covered services?	Sometimes. You generally must get your care and services from doctors, other health care providers, and hospitals in the plan’s network (except for emergency, urgent care, or out-of-area dialysis). In an HMOPOS plan, you may be able to get some services out of network for a higher copayment or coinsurance.
Do I need to choose a primary care doctor?	Usually. In most HMOs you need to choose a primary care doctor.
Do I have to get a referral to see a specialist?	Yes. In most cases, you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don't require a referral.
What else do I need to know?	If you get health care outside the plan's network, you may have to pay the full cost. If your plan gives you prior approval for a treatment, the approval must be valid for as long as the treatment’s medically necessary. Also, your plan can’t ask you to get additional approvals for that treatment. If you’re currently getting treatment and you switch to a new plan, you’ll have at least 90 days before the new plan can ask you to get a new prior approval for your ongoing treatment. If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another provider in the plan. Your plan can’t charge more than Original Medicare for certain services like chemotherapy, dialysis, and skilled nursing facility care. Check with the plan you’re interested in for specific information.

Questions you may have about PPOs

Question: Do these plans charge a monthly premium ?	Answer: Yes. These plans usually charge a premium, in addition to the monthly Part B (Medical Insurance) premium.
Do these plans offer Medicare drug coverage (Part D)?	Usually. Prescription drugs are covered in most PPO Plans. Check with the plan you’re interested in. PPOs & drug coverage If you want prescription drug coverage, you have to join a PPO that offers it. If you join a PPO that doesn’t offer drug coverage, you can’t join a separate Medicare drug plan.
Can I use any doctor or hospital that accepts Medicare for covered services?	Yes. You can also use out-of-network providers for covered services, if they’re participating in Medicare or accept assignment , but you'll usually pay more. Before you get services from an out-of-network provider, contact your PPO Plan to ensure the services are medically necessary and covered by your plan. You’re always covered for emergency and urgent care.
Do I need to choose a primary care doctor?	No.
Do I have to get a referral to see a specialist?	No.
What else do I need to know?	Because certain providers are "preferred," you can save money by using a PPO. Your plan can’t charge more than Original Medicare for certain services like chemotherapy, dialysis, and skilled nursing facility care. If your plan gives you prior approval for a treatment, the approval must be valid for as long as the treatment’s medically necessary. Also, your plan can’t ask you to get additional approvals for that treatment. If you’re currently getting treatment and you switch to a new plan, you’ll have at least 90 days before the new plan can ask you to get a new prior approval for your ongoing treatment.

Questions you may have about SNPs

Question:	Answer:
Do these plans charge a monthly premium ?	Varies by plan. Some plans may charge a premium, in addition to the monthly Part B (Medical Insurance) premium. However, if you have Medicare and Medicaid, most of the costs will be covered for you. Contact your Medicaid office for more information.
Do these plans offer Medicare drug coverage (Part D)?	Yes. All SNPs must provide Medicare drug coverage (Part D).
Can I use any doctor or hospital that accepts Medicare for covered services?	Varies by plan. Some SNPs require that you get your care and services from providers and facilities in the plan’s network (except for emergency care, out-of-area urgent care, or out-of-area dialysis). Some SNPs offer out-of-network coverage, so you can get services from any qualified provider or facility, but you’ll usually pay more.
Do I need to choose a primary care doctor?	Varies by plan. If you have primary care doctor or provider you like, ask the plan if you can keep them.
Do I have to get a referral to see a specialist?	Varies by plan. Referrals may be required for certain services but not others.
What else do I need to know?	D-SNPs can help coordinate your benefits between Medicare and Medicaid. If you’re interested in an I-SNP, and live in a facility, check that the plan has providers that serve people where you live. C-SNPs can limit membership to a single chronic condition or a group of related chronic conditions. All SNPs use a care coordinator to help you stay healthy and develop a care plan with you. You can stay enrolled in a Medicare SNP only if you continue to meet the condition served by the plan. If you're losing your plan because you no longer meet the plan's conditions, you may be eligible for a Special Enrollment Period to join another plan. Your plan can’t charge more than Original Medicare for certain services like chemotherapy, dialysis, and skilled nursing facility care. If your plan gives you prior approval for a treatment, the approval must be valid for as long as the treatment’s medically necessary. Also, your plan can’t ask you to get additional approvals for that treatment. If you’re currently getting treatment and you switch to a new plan, you’ll have at least 90 days before the new plan can ask you to get a new prior approval for your ongoing treatment. Check with the plan you’re interested in for specific information.

Questions you may have about PFFS plans

Question:	Answer:
Do these plans charge a monthly premium?	Yes. These plans usually charge a premium, in addition to the monthly Part B (Medical Insurance) premium.
Do these plans offer Medicare drug coverage (Part D)?	Sometimes. Prescription drugs may be covered. If your PFFS plan doesn’t offer drug coverage, you’ll need to join a separate Medicare drug plan (Part D) to get drug coverage.
Can I use any doctor or hospital that accepts Medicare for covered services?	You can go to any Medicare-approved provider or facility that accepts the plan’s payment terms, agrees to treat you, and hasn’t opted out of Medicare (for Part A- and Part B-covered items and services). If you join a PFFS plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You can also choose an out-of-network provider or facility who accepts the plan’s terms, but you may pay more. In an emergency, doctors, hospitals, and other providers must treat you.
Do I need to choose a primary care doctor?	No.
Do I have to get a referral to see a specialist?	No.
What else do I need to know?	The plan decides how much you pay for services. The plan will tell you about your costs in the “Annual Notice of Change” and “Evidence of Coverage” that it sends each year. You’ll need to show your plan membership ID card each time you go to a health care provider. Your provider can choose at every visit whether to accept your plan’s terms and conditions of payment. You can’t use your red, white, and blue Medicare card to get heath care because Original Medicare won’t pay for your health care while you’re in a PFFS plan. Keep your Medicare card in a safe place in case you return to Original Medicare in the future. Your plan can’t charge more than Original Medicare for certain services like chemotherapy, dialysis, and skilled nursing facility care. If your plan gives you prior approval for a treatment, the approval must be valid for as long as the treatment’s medically necessary. Also, your plan can’t ask you to get additional approvals for that treatment. If you’re currently getting treatment and you switch to a new plan, you’ll have at least 90 days before the new plan can ask you to get a new prior approval for your ongoing treatment. Check with the plan you’re interested in for specific information.

Questions you may have about MSAs

Question:	Answer:
Do these plans charge a monthly premium ?	No, but you must continue to pay your monthly Part B (Medical Insurance) premium.
Do these plans offer Medicare drug coverage (Part D)?	No. If you join a Medicare MSA Plan and want Medicare drug coverage, you'll have to join a separate Medicare drug plan. Find drug plans in your area.
Can I use any doctor or hospital that accepts Medicare for covered services?	Yes. MSA Plans generally don't have a network of health care providers. You can get covered services from any Medicare provider in the U.S. or U.S. territories.
Do I need to choose a primary care doctor?	No.
Do I have to get a referral to see a specialist?	No.
What else do I need to know?	MSA Plans cover the Medicare services that all Medicare Advantage Plans must cover. Some MSA plans also cover extra benefits like dental, vision, and hearing services. You may pay a premium for this extra coverage. Check with the plan you’re interested in for information on what extra benefits they offer, if any. Your plan can’t charge more than Original Medicare for certain services like chemotherapy, dialysis, and skilled nursing facility care. If your plan gives you prior approval for a treatment, the approval must be valid for as long as the treatment’s medically necessary. Also, your plan can’t ask you to get additional approvals for that treatment. If you’re currently getting treatment and you switch to a new plan, you’ll have at least 90 days before the new plan can ask you to get a new prior approval for your ongoing treatment. 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. 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. Money left in your account at the end of the year stays there, and may be used for health care costs in future years. Learn how MSA Plans work with other coverage.

Compare Types of Medicare Advantage Plans

Plan Type	HMO Health Maintenance Organization	PPO Preferred Provider Organization	PFFS Private Fee-for-Service (PFFS) Plan	SNP Special Needs Plan	MSA Medicare Savings Account
Premium Do most plans charge a monthly premium?	Yes Many charge a premium in addition to the monthly Part B premium.	Yes Many charge a premium in addition to the monthly Part B premium.	Yes Many charge a premium in addition to the monthly Part B premium.	Yes Many charge a premium in addition to the monthly Part B premium.	No You won't have to pay a separate monthly premium, but you'll continue to pay your Part B premium.
Drugs Does the plan offer Medicare prescription drug coverage (Part D)?	Usually If you join an HMO plan that doesn’t offer drug coverage, you can't get a separate Medicare drug plan.	Usually If you join a PPO plan that doesn’t offer drug coverage, you can't get a separate Medicare drug plan.	Usually If your PFFS Plan that doesn’t offer drug coverage, you can get a separate Medicare drug plan.	Yes All SNPs must provide Medicare drug coverage (Part D).	No You may join a separate Medicare drug plan.
Providers Can I use any doctor or hospital that accepts Medicare for covered services?	Sometimes You generally must get your care and services from doctors, other providers, or hospitals in the plan’s network (except emergency or urgent care or out-of-area dialysis). In an HMO Point-of-Service (HMOPOS) Plan 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. You may also go out of the plan’s network, but your costs may be higher.	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-of-network provider that accepts the plan’s terms, you may pay more.)	Sometimes If your SNP is an HMO, you must get your care and services from doctors or hospitals in the SNP's network (except for emergency, urgent care, or out-of-area dialysis). However, if your SNP is a PPO, you can get Medicare-covered services out of network.	Yes MSA plans generally don’t have network providers. You may go to any Medicare-approved provider for services that Original Medicare covers.
Primary Care Do I need to choose a primary care doctor?	Usually	No	No	Varies by plan Some SNPs require you to choose a primary care doctor and others don’t.	No
Referrals Do I need a referral from my doctor to use a specialist?	Yes	No	No	Maybe If the SNPs is an HMO, you need a referral. If the SNP is a PPO, you don't need a referral.	No

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