Medicare Parts and Networks

Part A 

Medicare Part A covers you if admitted as an “In-patient” to a hospital, skilled nursing facility or institution. Part A is free if you have paid into Social Security and has very high deductibles. Part A only covers 80% of costs which means you pay the 20%. Part A covers what anything that happens inside a hospital.

Part B

Medicare Part B is not free, and you pay a monthly deductible. Part B covers anything that happens outside of the hospital.

Part C

Medicare Part C is your Advantage plan. Plans have network definitions like HMO, POS, PPO, PFFS, or HMO.

Part D

Medicare Part D is your medication prescription plan. It is generally included in your Advantage plan, but some plans do not offer Part D and are called MA only plans. Depending on the plan you select you can enroll in a plan with or without Part D. Supplemental plans do not include Part D so you will need to have a separate stand-alone medication plan.

Definitions of plan Network types.

HMO

HMO (Health Maintenance Organization) plans have a providers’ network, except for emergency care or out-of-area urgent care or out-of-area dialysis. Some plans are a combination of an HMO and POS or an HMO and PPO plan. This means you would pay higher cost for out-of-network POS or PPO care. Most plans offer prescription coverage, and you cannot have a stand-alone Part D plan at the same time. Most plans require you to select a primary care provider or clinic. Some plans require prior approval for certain services.

POS

POS (Point of Service) plans generally have you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans also require you to get a referral from your primary care doctor to see a specialist.

 
PPO

PPO (Preferred Provider Organizations) plans have network doctors, other health care providers, and hospitals. You pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. You pay more if you use doctors, hospitals, and providers outside of the network. In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. You do not have to select a primary care physician. Some plans have “preferred” provider networks. Each plan gives you flexibility to go to doctors, specialists, or hospitals that are not on the plan's list, but it will usually cost more. Most plans include prescription coverage. If you join a PPO Plan that does not offer prescription drug coverage, you cannot join a stand-alone Part D prescription plan.

PFFS

PFFS (Pay for Fee Services) plans determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care. 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. You do not have to select a primary care physician or have a referral to get care. If you join a PFFS Plan that has a network, you can also see any of the network providers who have agreed to treat plan members. You can also choose an out-of-network doctor, hospital, or other provider, who accepts the plan's terms, but your costs will usually be lower if you stay within the network.

Medicare Savings Accounts

MSA (Medicare Savings Accounts) combine a high-deductible insurance plan with a medical savings account that you can use to pay for your health care costs. MSA plans do not include Part D prescription coverage and you would need to enroll in a stand-alone Part D plan. The high-deductible health plan will only begin to cover your costs once you meet a high yearly out-of-pocket deductible. The MSA Plan deposits money into your account, generally held by your bank. You can use money from this savings account to pay your health care costs before you meet the deductible.

Definations of plan Networks

Medicare Advantage 

These plans have defined networks, while other Advantage plans allow you to use both In-Network and out-of-network care.
 

Medicare Supplemental

These plans do not have a defined network, so you can go to any doctor, clinic, hospital, specialty care in the US, if they accept and bill Medicare.
 

Primary Care Physician

Some plans require you to have a designated clinic or a primary care physician and must have a referral.
 

Out-of-State Networks

Some plans offer Travel or Visitor benefits that allow you to be out-of-state for 9-months and you only pay your Minnesota co-pay for medical services. Other plans allow you to see health care providers but at a higher monthly premium and higher out-of-pocket co-pay.

International Networks

Some plans cover limited out of US medical services. Medicare only pays for Emergency care. You would pay out-of-pocket costs then submit the receipt to your plan for reimbursement if it is allowed in your plan.