Medicare Advantage Plans are a great way to ease the financial strain that comes with paying for healthcare. These plans provide additional coverage that is not included in the original Medicare Part A and Part B.

However, unlike Medicare Part A and Part B, Medicare Advantage plans are not administered by the Federal Government. Instead, these plans are provided by private insurance companies.

Let us take a look at the different Medicare Advantage Plans in Texas:

Health Maintenance Organizations (HMOs)

Under this system of health coverage, you can avail of a wide range of health care services through a network of doctors, hospitals, and health care providers who are under contract with the HMO.

The insured person must choose a primary care physician (PCP) from the network of local health care providers under an HMO plan. Your PCP will serve as the primary point of contact for all your health care needs. If you need specialist care, your PCP will make a referral to a specialist who is part of the HMO network.

As long as you are visiting someone from within the network, your insurance company will cover some of the costs. You will have to pay part of the expenses. But once you pay that amount (copayment or deductible), your insurer will start covering your costs.

Medical entities that are in contract with the HMO have the advantage of having patients directed to them. Also, they are reimbursed using capitation arrangements.

As a result, HMOs can offer lower premiums to subscribers than other types of health insurance plans at the same time retaining a high quality of medical care from its network.

HMO subscribers have to pay this premium monthly or yearly. But they are limited to receiving their medical care from doctors, hospitals, and health care providers within the HMO network. However, some out of network services such as emergency care and dialysis can be covered under the HMO.

Preferred Provider Organizations (PPOs)

This is similar to HMOs in that they operate with a specific network of doctors, hospitals, and health care providers. Subscribers are given medical care at a reduced rate. In exchange for reduced rates, insurers pay the PPO a fee to access its network of providers. 

PPOs do not always require patients to seek medical care from medical entities within the network. Out of network care is available but it costs more for the insured. Patients need to confirm coverage before selecting a provider as PPOs may deny some coverage for out of network providers.

PPO subscribers typically make a copayment per provider visit or they must meet the deductible expenses before insurance pays for the claim.

Provider Sponsored Organizations (PSOs)

This is also similar to HMOs in that participants are required to receive medical care within their network. However, PSOs are run by healthcare providers themselves who are typically doctors within primary care or hospital settings.

Only in some cases, physicians may refer to specialists outside of the organization.

Special Needs Plans (SNPs)

SNPs are specifically designed for individuals with disabilities or chronic illnesses. These plans include prescription drug coverage and care services that are coordinated between the patient’s physician and the insurance provider.

Most SNPs require the patient to be diagnosed with a long term condition or illness or be dually eligible for both Medicare and Medicaid.

Private Fee for Service Plans (PFFPs)

Private Fee for Service plans are the most flexible Medicare Advantage Plans in Texas. In these plans, the insurance provider pays a predetermined amount for each health care service while the patient is responsible for the remainder of the cost.

Under this plan, the patient is free to receive care from an approved health care provider instead of being limited to practitioners within a limited network.

What is the Eligibility Criteria for Medicare Advantage Plans?

Seniors who are eligible for Medicare Part A and Part B are also eligible to enroll in Medicare Advantage plans.

What are the Advantages of Medicare Advantage Plans?

Compared to original Medicare, these are some of the advantages of Medicare Advantage Plans:

• Convenient Coverage options

• Personalized Plan structures

• Coordinated Medical care

• Cost-saving opportunities

So do you have any questions about the Medicare Advantage Plans in Texas?