Medicare Advantage Plans

With Original Medicare, the member has Medicare Part A (Hospital), Medicare Part B (Medical Services) as the primary insurance, and a Medicare Supplement (or Medigap policy) as supplementary coverage. The doctor or hospital sends bills to Medicare and Medicare pays its portion; then Medicare passes the bill on to the Medicare Supplement Company, that pays the remaining costs. The member also buys a separate Part D Prescription Drug plan on the Medicare.gov website.

A Medicare Advantage plan is different from a Medicare Supplement plan. Medicare sends funding to the insurance company to administer a plan for its members. It is a private health insurance plan approved by Medicare and administered by an Insurance Company.  These plans include coverage for Medicare Part A (Hospital), Medicare Part B (Medical Services) and Medicare Part D (Prescription Drugs) in one plan.

In Santa Barbara County there are two kinds of Advantage Plans available: Medicare HMO and Medicare PPO

Medicare HMO

  • These plans have an HMO network. You can only use doctors and hospitals in the HMO network.  In Santa Barbara Sansum Medical Clinic and Santa Barbara Select are examples HMO groups.
  • You will choose a primary care physician who manages you care and makes referrals to specialists within the network.
  • Often there is no deductible for medical services. The member has copays for most medical services, including Hospital costs.
  • There is an out-of-pocket maximum for copays.  Medicare sets the maximum value at $7,550, but the insurance company can set a lower amount.
  • This plan includes a prescription drug plan.

Medicare PPO

  • These plans have a PPO provider network, which is larger than an HMO network.
  • Often there is no deductible and you pay copays for services.
  • You can go outside the network to any provider contracted by Medicare and have higher copays.
  • There is an out-of-pocket maximum for copays.  Medicare sets the maximum value at $7,550, but the insurance company can set a lower amount.  If you use both in- and out-of-network providers, there is a higher out-of-pocket maximum.
  • Plan includes a prescription drug plan.