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How are Medicare Advantage plans different from Original Medicare?

En español |The private plans operate differently from original Medicare in several ways. About two-thirds of the Medicare Advantage plans sold in 2017 are HMOs (health maintenance organizations), which require members to go to health care providers who are part of the plan's provider network limited to a specific geographic area. Some Medicare Advantage plans that are PPOs (preferred provider organizations) allow members to go to providers outside the plan network at an additional cost.

Participating doctors and other providers can change during the year, but with a few exceptions, members cannot change plans to stay with their doctors. Network restrictions don't apply if you need urgent or emergency care, and your Medicare Advantage will pay for the services you receive.

Restricting members to provider networks and other efficiencies enable Medicare Advantage plans to offer benefits not available in original Medicare. These may include lower premiums than original Medicare and dental and vision care, hearing aids and health club memberships. The extent of these benefits can vary from plan to plan. 

In addition, Medicare Advantage rules require plans to cap members' out-of-pocket expenses for Part A and B services from in-network providers (excluding drug spending). In 2017, that limit is $6,700, although the average plan's limit is $5,332, according to a recent analysis. Higher limits are allowed for services received from out-of-network providers.

By comparison, original Medicare has no limit on the amount of Part A and B copayments and coinsurance beneficiaries might have to pay.

     

        


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