Why are my Medicare benefits different from my friend’s plan with the same company?


If only we got a dime every time we got asked this question… lol. The answer is simple, but multifaceted. In short, most insurance carriers offer multiple plans and each of those plan’s features and benefits will vary. When shopping for your Medicare Advantage plan here are a few things to keep an eye out for.  

In most regions throughout the Tampa Bay area there are roughly 55 Medicare advantage plans available in each, give or take a few. Out of the available plans there are two main types you will encounter: PPO’s, HMO’s. Out of these two, there are several subcategories to be mindful of. For example: Part B reduction plans, Chronic Illness plans, and Dual Eligible plans. Ultimately the type of plan, not necessarily the company offering the plan, is what will determine how feature rich the benefits will be.

Let’s say for example that both you and your friend live in Valrico, Fl. The both of you have a Medicare Advantage plan through Optimum insurance. After a discussion you have one day over coffee, you find out that your friend has a plan with a lower maximum out of pocket, and greater OTC benefits than you do. What is important to consider is whether the types of plans you have are the same, not just the carrier. Generally speaking, HMO’s have some extras that PPO’s do not, and Special Needs/Dual Eligible plans have even greater benefits than a regular HMO does.  

So what makes these plans different???

PPO’s, or Preferred Provider Organizations, offer you the greatest flexibility in terms of seeking out the doctors of your choice. With  a PPO, you have the option to see any in network doctor you would like, without the need for a referral from your primary care physician. If the doctor you’d like to see is out of network, you can still visit them by simply paying an out-of-network premium to do so. This type of plan suits anyone that doesn’t want to wait for referrals, and would like the option to see a doctor that may not be in the network. Although most MAPD PPO’s are available at $0 monthly premiums, you can expect your portion of cost sharing (co-pays, max out-of-pocket etc) to be greater than with HMO plans. 

HMO’s, or Health Maintenance Organizations, differ from PPO’s in that they function more like managed care. In an HMO, your primary doctor is responsible for determining the care that you need and referring you to specialists, testing, etc as needed. In an HMO there is no out-of-network service. Any doctor that you visit, must be part of the group of physicians selected by the plan. In exchange for a smaller doctor network and managed care, the greatest value of an MAPD HMO is that you will have a lower portion of cost sharing. So your co-pays and yearly maximum out of pocket will be considerably lower than with a PPO.

Part B reduction plans are HMO’s that offer you the added benefit of having a portion of your part B premium given back to you. The amount of the giveback will vary depending on the area you live in. On average, in areas like ours – Brandon, Valrico, Plant City, Thonotosassa, Lakeland, Riverview, and other areas surrounding Tampa Bay, these plans will give you back anywhere from $50-$140  each month. Even though it sounds too good to be true, these plans do exist. The drawback??? Smaller doctor networks and the need for referrals. Keep in mind that these plans work great for the right kind of person, and just because the network of doctors is smaller doesn’t mean that you have to sacrifice on your quality of care. 

Chronic illness plans are exactly what they sound like. If you have a qualifying condition, you are eligible for what’s called a C-SNP (Chronic Special Needs Plan). In some cases, chronic illness plans also have a part B giveback. The only difference between this and a traditional HMO is that the benefits will be slightly more generous and your cost sharing will be even less. Qualifying conditions for this type of plan are: autoimmune disorders, cancer, cardiovascular disorders, chronic heart failure, chronic lung disorders, hematologic disorders, HIV/AIDS, neurologic disorders, dementia, diabetes and ESRD. 

Last on the list is a Dual Eligible plan, or D-SNP. In order to qualify for this type of plan you must be eligible for both Medicare and Medicaid. These plans are available in both HMO’s and PPO’s and the amount of cost sharing will ultimately be determined by your qualifying level of dual eligibility. See chart below for levels.


As you can see, there is quite a bit of information that must be considered, not only when you go about choosing your plan, but also when comparing your plan to someone else. It can get tricky, but we are here to help. If you have any questions whatsoever, please reach out to us. Someone from our team will be happy to walk you through it.

Medicare Information Project

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