White Paper: Understanding Medicare Advantage Payment & Policy Recommendations 3
high of 44% in Oregon.
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This variation is due to many factors, including long-term insurance
market factors in states as well as specific characteristics of each state – for example,
low penetration rates due to a state being rural and sparsely populated (e.g. Vermont,
Wyoming), high penetration rates due to a concentration of retirees (e.g. Florida, Arizona),
or a large number of hospital-owned plans (e.g. Minnesota, Oregon).
Beneficiary access to Medicare Advantage is strong. In 2018, Medicare Advantage included
2,317 individual plan options.
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In total, 99% of all Medicare beneficiaries have access to a
Medicare Advantage plan and most beneficiaries have multiple plans to choose from in their
area.
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A recent analysis found that 90% of Medicare Advantage beneficiaries have a choice
of at least five Medicare Advantage plan options, 71% have at least 10 plans options, and
55% have at least 15 plan options.
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More than 80% of all beneficiaries have access to at least
one zero premium plan, and 40% of beneficiaries are enrolled in a zero premium plan.
D. Types of Medicare Advantage Plans
Medicare Advantage plans oer coordinated care, typically organized around a network of
health care providers that works to manage enrollees’ care. Each Medicare Advantage plan
establishes its own network of providers, subject to legislative and regulatory requirements
that determine the number and type of providers that must be included in a plan’s service
area.
The types of Medicare Advantage plans available to beneficiaries are:
1. Health Maintenance Organizations (HMOs): HMOs often require members to choose a
primary care physician to coordinate their care and utilize network providers or pay the
full cost of care received outside the network. Generally, HMOs require a referral from
a primary care physician to see a specialist. In 2018, more than 60% of enrollees are in
HMOs.
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2. Preferred Provider Organizations (PPOs): PPOs are similar to HMOs, but they may not
require members to select a primary care physician, and they often do not require a
referral to see a specialist. They may oer coverage for health care services received
outside the network, but typically require members to pay a larger portion of the cost of
out-of-network care. PPOs may be local (county-specific) or regional (span two or more
states). In 2018, approximately 34% of enrollees are in PPOs.
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3. Private Fee-For-Service (PFFS): PFFS plans allow enrollees to see any Medicare-eligible
health care provider who accepts payment from that plan; however, they may oer
members financial incentives to use certain providers. Just 1% of Medicare Advantage
enrollees selected a (PFFS) plan. In 2018, less than 1% of enrollees are in PFFS plans.
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4. Special Needs Plans (SNPs): SNPs are a type of Medicare Advantage plan tailored to
serve frail, disabled, and chronically-ill beneficiaries. There are SNPs tailored to enrollees
who are dually eligible for both Medicare and Medicaid, those who have a severe or
disabling chronic condition, or those who live in a nursing home or who require skilled