Types of Medicare Advantage Plans in 2026

Curious about the types of Medicare Advantage plans in 2026? This guide covers all the available options, including HMOs, PPOs, and specialized plans, and explains any new updates and changes you should be aware of. Stay informed to make the best healthcare choice for the coming years.

Key Takeaways

• Medicare Advantage plans, provided by private insurers, cover all Original Medicare services and often include additional benefits such as dental and vision coverage.

• Different types of Medicare Advantage plans include HMO, PPO, PFFS, SNPs, and MSA plans, each with unique features regarding provider access and cost management.

• Selecting the right Medicare Advantage plan requires careful evaluation of healthcare needs, provider networks, and an understanding of associated costs, including premiums and out-of-pocket limits.

Medicare Advantage plans, also known as Medicare Part C, offer an alternative to traditional Medicare. These plans are provided by private insurance companies that have a Medicare contract and must cover all services that Original Medicare covers. One of the appealing aspects of Medicare Advantage plans is that they often include additional benefits not found in Original Medicare, such as dental, vision, and hearing coverage.

It’s important to note that Medicare Advantage plans offered in Texas may be significantly different than those offered in another state. You must live in the region where the plan is offered to enroll.

By enrolling in a Medicare Advantage plan, you receive your Medicare coverage through a private insurer without losing your benefits. These plans can also offer prescription drug coverage, which is a significant advantage for those who require ongoing medications. Another noteworthy point is that these plans cannot charge more for certain services than Original Medicare would charge.

Medicare Advantage plans vary by location and may offer different features and benefits depending on the area. Typically, these plans charge a monthly premium in addition to the Part B premium, but the exact costs can vary. Reviewing the specific details of each plan available in your area helps you find the best fit for your needs.

Health Maintenance Organization (HMO) Plans

Health Maintenance Organization (HMO) plans are a popular type of Medicare Advantage plan. These plans generally require members to use healthcare providers within the plan’s network for non-emergency services. The network requirement helps keep costs lower, making HMO plans a cost-effective choice for many Medicare beneficiaries.

Members of HMO plans usually need to select a primary care provider who oversees their healthcare and provides referrals to doctors and specialists. While HMO plans often feature lower premiums and cost-sharing requirements compared to other Medicare Advantage plans, preventive care received outside of the network can result in higher out-of-pocket costs unless it’s an emergency. Some services within HMO plans may also require prior approval to confirm they are medically necessary.

Preferred Provider Organization (PPO) Plans

Preferred Provider Organization (PPO) plans offer greater flexibility compared to HMO plans. These plans allow members to:

• See any doctor or hospital that accepts Medicare, providing more freedom in choosing healthcare providers.
• Avoid the requirement to select a primary care doctor.
• No need for referrals to see specialists, unlike HMO plans.

While PPO plans offer flexibility, members typically pay less when using healthcare providers within the plan’s network. Key points about PPO plans include:

• Emergency and urgent care services are always covered, regardless of whether the provider is in-network or out of network services.
• Accessing providers can vary depending on the plan.
• Some plans may require the use of network providers.

Private Fee-for-Service (PFFS) Plans

Private Fee-for-Service (PFFS) plans are another type of Medicare Advantage plan. These plans determine the payment amounts for healthcare providers and the cost-sharing responsibilities of patients. PFFS plans offer the flexibility to see any provider who accepts the plan’s payment terms, giving beneficiaries more freedom in choosing their healthcare providers.

However, not all providers and other providers accept PFFS plans. Therefore, verifying that your chosen providers are willing to accept the plan’s payment terms before enrolling is crucial. This flexibility can be both an advantage and a limitation, making it necessary to carefully consider your healthcare needs and provider availability.

Special Needs Plans (SNPs)

Special Needs Plans (SNPs) are tailored for individuals with specific health conditions or circumstances. There are three main types of SNPs: Dual Eligible SNPs (D-SNP), Chronic Condition SNPs (C-SNP), and Institutional SNPs (I-SNP). These plans are designed to cater to individuals with severe or chronic diseases, unique health care requirements, or those who are also eligible for Medicaid.

Eligibility for SNPs requires individuals to have both Medicare Part A and Part B and reside within the plan’s designated service area. SNPs typically offer care coordination services and customize benefits and provider options to meet the specific needs of their members.

SNPs can only maintain enrollment for members who continue to meet the specific eligibility criteria defined by the plan, with certain limitations.

Prescription Drug Coverage in Medicare Advantage Plans

Prescription drug coverage is an essential aspect of many Medicare Advantage plans. Since not all Medicare Advantage plans provide separate drug coverage, enrolling in a plan that includes it is important if you require ongoing medications. All Special Needs Plans (SNPs) must include Medicare prescription drug coverage (Part D) as part of their benefits.

PFFS plans may or may not include Medicare Part D drug coverage; if not, members must enroll in a separate drug plan. Most HMO and PPO plans include coverage for prescription medications, but not all plans specifically offer this benefit.

When comparing plans, check whether they include prescription drug coverage, as many offer this benefit.

Extra Benefits Offered by Medicare Advantage Plans

Many Medicare Advantage plans include additional benefits that go beyond what Original Medicare offers, including covered services. Dental coverage, for instance, can range from routine cleanings to more extensive procedures like dentures and root canals. Vision benefits typically cover routine eye exams and can provide discounts on eyewear, including glasses and contact lenses.

Hearing services, often included in Medicare Advantage plans, cover routine check-ups and can help with the cost of hearing aids. Some plans also offer wellness programs that may include gym memberships, fitness classes, and preventive health services to support overall health. These extra benefits, including hearing benefits, can make a significant difference in the overall value of the plan. Additionally, UnitedHealthcare offers these valuable services to enhance the benefits of its plans.

Enrollment Periods for Medicare Advantage Plans

Knowing the enrollment periods for Medicare Advantage plans is crucial for timely and effective coverage. The Initial Enrollment Period spans seven months, starting three months before you turn 65 and ending three months after your birthday month. The Annual Enrollment Period, from October 15 to December 7, allows individuals to change their Medicare plans.

The Special Enrollment Period permits beneficiaries to switch or enroll in Medicare plans based on significant life events, such as moving or losing current coverage.

Those already enrolled in a Medicare Advantage plan can make one-time changes during the Medicare Advantage Open Enrollment Period from January 1 to March 31 each calendar year. If you miss your Initial Enrollment Period, you can enroll during the General Enrollment Period from January 1 to March 31, with coverage starting on July 1.

Costs Associated with Medicare Advantage Plans

The costs associated with Medicare Advantage plans can vary significantly based on the specific plan chosen. These expenses include:

• Premiums
• Deductibles
• Copayments
• Coinsurance

The average monthly premium for all Medicare Advantage plans, including those with prescription drug coverage, is projected to slightly increase from $17.86 to $18.50 in 2024.

Each Medicare Advantage plan has an out-of-pocket limit, which varies, ensuring full coverage of health services once the limit is reached. Beneficiaries must continue paying their Part B premium while enrolled in a Medicare Advantage plan.

Additionally, those with very high drug costs will have a cap on their out-of-pocket expenses in the catastrophic phase of the Medicare Part D benefit. Reviewing the specific rising costs and coverage details of each plan helps understand how to lower costs and the potential financial impact.

Choosing the Right Medicare Advantage Plan

Choosing the right Medicare Advantage plan involves careful consideration of several factors. First, consider your preferred healthcare providers, as some plans may restrict you to a specific network. Evaluating out-of-pocket costs is also crucial, as expenses can vary significantly between different Medicare Advantage plans based on their coverage and deductibles.

Compare the plan options available in your area and consult with a Medicare advisor if needed. Taking the time to review and understand the benefits, costs, and provider networks of each plan can help ensure you choose the Medicare Advantage plan options that best meet your healthcare needs and financial situation.

How to Enroll in a Medicare Advantage Plan

To enroll in a Medicare Advantage plan, you need to:

• Have Medicare Part A and Part B, as this is a prerequisite for enrollment.
• Live in the service area of the plan you wish to join.
• Have your Medicare Number and the start dates of your Part A and/or Part B, which are essential for enrollment.

Once you select a plan type, you can enroll online, by contacting the plan directly, or by submitting a paper form. It’s important to verify that the chosen plan covers your medications and includes necessary benefits.

Having all the required information and understanding the enrollment process can make the transition to a Medicare Advantage plan smooth and straightforward, allowing you to enjoy all the benefits.