Resource CenterFederal/State BenefitsMedicaid & MedicarePrivate Medicare Plans

4.3. Private Medicare Plans

A private Medicare plan is health care benefits offered by a private insurance company. These are often used to replace or to subsidize Medicare benefits. Most often private Medicare plans aren't the same as Original Medicare or Medigap. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.

Private Medicare Plans vary in how and where services can be obtained. 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. Not all providers will. If you join a PFFS Plan that has a network, you can also see any of the network providers who have agreed to always treat plan members. You can also choose an out-of-network doctor, hospital, or other provider, who accepts the plan's terms, but you may pay more.

Some plans contract with a network of providers who agree to always treat you even if you've never seen them before. Out-of-network doctors, hospitals, and other providers may decide not to treat you even if you've seen them before. For each service you get, make sure your doctors, hospitals, and other providers agree to treat you under the plan, and accept the plan's payment terms. In an emergency, doctors, hospitals, and other providers must treat you. Show your plan membership ID card each time you visit 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 health care because Original Medicare won't pay for your health care while you're in the Medicare PFFS Plan. Keep your Medicare card in a safe place in case you return to Original Medicare in the future. You only need to pay the copayment or coinsurance amount allowed by the plan for the type(s) of service you get at the time of the service.

Types of Private Medicare Plans

Medicare Special Needs Plans (SNP)
Medicare SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics, and tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. Generally, you must get your care and services from doctors or hospitals in the Medicare SNP network (except emergency or urgent care, such as care you get for a sudden illness or injury that needs medical care right away, or if you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis). Medicare SNPs typically have specialists in the diseases or conditions that affect their members. Find out who can join a Medicare SNP.

Health Maintenance Organization (HMO) Plan
In HMO Plans, you can't get your health care from any doctor, other health care provider, or hospital. You generally must get your care and services from doctors, other health care providers, or hospitals in the plan's network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services, usually for a higher cost. This is called an HMO with a point-of-service (POS) option. Find and compare HMO Plans in your area

Preferred Provider Organization (PPO) Plans
A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. In a PPO Plan, 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. Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren't on the plan's list, but it will usually cost more. A PPO Plan isn't the same as Original Medicare or a Medicare Supplement Insurance (Medigap) policy. PPO Plans usually offer extra benefits than Original Medicare, but you may have to pay extra for these benefits.

Private Fee-for-Service (PFFS) Plans
A Medicare PFFS Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PFFS plans aren't the same as Original Medicare or Medigap. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you 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 always treat plan members. You can also choose an out-of-network doctor, hospital, or other provider, who accepts the plan's terms, but you may pay more.

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