What Is A Medicare Ppo Plan
PPO stands for Preferred Provider Organization.
With a Medicare PPO, you are free to visit the health care provider of your choice. The PPO plan will have a network of providers , and you will typically have lower out-of-pocket costs if you stay within that network.
Unlike an HMO plan, a PPO plan my cover some of the costs for care you receive outside of the plan network. However, you will likely pay higher out-of-pocket costs for care you receive outside of the network.
You are typically not required to designate a primary care physician when you join a PPO plan. This can give you a little more freedom to choose your providers and to seek the care of a specialist without having to get a referral from a primary care doctor.
Some Medicare PPO plans are local PPO plans, and some are regional PPO plans. These designations have to do with the specific plan coverage area.
The Most Popular Type Of Medicare Advantage Plan: Hmo Plans
With an HMO, you may have less choice in who you can see for care, but your out-of-pocket costs are often lower than other plans like PPOs that provide more options. For in-network services, Kaiser reports that the average out-of-pocket limit on HMO plans is $4,566, compared with an average limit for all Advantage plans of $5,091. But patients must stay within a network of health providers, except for emergency care.
Medicare Advantage HMOs almost always require enrollees to go to doctors and facilities within their own provider networks and limited geographical areas and to obtain referrals to see specialists, Patricia Barry explains.
Typically with an HMO, youd have to pay the entire bill for healthcare outside the network.
Given that there are more HMO Advantage plans than any other type, you should have multiple options. But if youre getting it through your employer, youll be limited to whats offered, and there are local and regional limits on what plans are available.
What Is A Medicare Advantage
Medicare Advantage plans are an alternative to Traditional Medicare, also known as Medicare Part C. The federal government provides subsidies to private insurance companies to sell these plans and allow competition in the marketplace. Medicare Advantage typically combines coverage for outpatient treatment, hospital or skilled nursing stays, and prescription drugs. There are two main types of Medicare Advantage policies: HMO plans and PPO plans. A Medicare Advantage HMO plan functions in a similar way to traditional HMO coverage. There are a network of doctors, hospitals, and clinics who have agreed to accept the insurance, so if you want your costs to be covered, your treatment must come from in-network providers. Most Medicare Advantage HMO plans also require their policyholders to have a primary care physician, or PCP, who coordinates their treatment. If you need to see a specialist or undergo a test, youll first visit your PCP for a referral. You have probably seen advertisements on TV for HMOs that are very misleading. The ads boast $0 premiums and no costs, meanwhile members are usually still required to pay the Part B premium and other costs as well.
Read Also: When To Sign Up For Medicare Part D
How To Decide Which Is Better For You
Choosing the best Medicare Advantage plan depends entirely on your personal medical and financial situation. What works for another person may not work for you, so its important to do your research on the plans in your area.
Here are a few things to consider when choosing whether to enroll in a PPO or HMO Advantage plan:
- Provider networks. If you value provider flexibility, a PPO plan may be your best option. If youre fine with using only in-network providers, an HMO plan could work for you and cost less.
- Coverage. Your coverage options are specific to each plan, but there is usually no major difference between the coverage options of most PPO and HMO Advantage plans.
- Costs. Medicare AdvantagePPO and HMO plans differ in their costs depending on what state you live in and what type of coverage youre looking for. There may be additional costs associated with your plan depending on whether you stay in network or not.
- Availability. Medicare Advantage plans are location-based, meaning that you must enroll in the state in which you currently live and receive medical services. Some private companies will only offer one type of plan, while others will have multiple types to choose from.
Medicare Hmo Plans Vs Medicare Ppo Plans: What Is The Difference
Medicare Advantage plans are a type of umbrella plan that combines hospital, medical and prescription coverage through a private insurance company. These plans are similar to traditional insurance as they operate off of a network like an HMO or PPO. The biggest difference between the two being provider flexibility, among other things.
Medicare Advantage HMO plans offer some of the following features:
- Must choose a primary care physician.
- Must use in-network providers for covered services.
- Most plans require a referral to see an in-network specialist.
With an HMO you typically must use network providers unless it is an emergency or urgent situation. Some carriers have forgone the referral aspect of a traditional HMO, so you may be able to see specialists without one depending on the plan you have. HMO plans typically have lower copays and out of pocket maximums.
Medicare Advantage PPO plans offer some of the following features:
- Many plans do not require you to choose a primary care physician.
- Offer coverage for in-network and out-of-network providers
- Most plans do not require a referral to see a specialist.
As you can see, there are key differences between Medicare HMO plans and Medicare PPO plans. Remembereveryones needs are different, and you are the best judge of which coverage would work best for you.
How Does A Ppo Plan Work
A PPO plan is also a Medicare Advantage Plan , but it works differently than an HMO plan. With a PPO plan, you dont have a PCP. Instead, you can access any doctor or hospital, but you would be responsible for coordinating your care. Seeing doctors inside the network will generally have lower costs for services than seeing a doctor outside of the network. A PPO plan provides everything Medicare covers plus additional benefits such as prescription drug coverage , vision and hearing exams, preventive dental coverage, and more. A PPO plan can have a monthly premium as low as $0 and an out-of-pocket maximum that limits what you pay for medical services in a year.
The Role Of The Primary Care Physician
The insured party must choose a primary care physician from the network of local healthcare providers under an HMO plan. A primary care physician is typically an individuals first point of contact for all health-related issues. This means that an insured person cannot see a specialist without first receiving a referral from their PCP.
However, certain specialized services, such as screening mammograms, do not require referrals. Specialists to whom PCPs typically refer insured members are within the HMO coverage, so their services are covered under the HMO plan after co-pays are made. If a primary care physician leaves the network, subscribers are notified and are required to choose another PCP from within the HMO plan.
Recommended Reading: What Is The Average Premium For Medicare Advantage Plans
What Else Do I Need To Know About This Type Of Plan
- If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.
- If you get health care outside the plan’snetwork, you may have to pay the full cost.
- It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.
Advantages Of Medicare Advantage Hmos
HMO plans are a popular choice among Medicare Advantage plans, which means plenty of variety in available options. In most major cities, you can easily find plans that have low-cost premiums, deductibles, and copayments.
The popularity of Medicare HMO plans also means that you will have a wide in-network selection of providers to choose from.
Also Check: Is Medicare A Form Of Socialism
What’s A Medicare Hmo
Health maintenance organizations of today aren’t like the HMOs of the past. Some HMOs have a point of service option as well.
Most HMOs provide care through a network of doctors, hospitals and other medical professionals that you must use to be covered for your care. With an HMO-POS you can go outside of the network for care, but you’ll pay more.
- You’ll need to choose a primary care physician to coordinate all your care.
- You typically don’t need a referral to see a specialist, but your doctor can sometimes help you get in to see one more quickly.
- You’ll need to work with your doctor to get prior authorization before you get some services. If you don’t get prior authorization, some services may not be covered.
- The HMO and POS portions of the plan have separate deductibles. Care you receive in-network through the HMO has a different deductible than care you receive out-of-network through the POS. The two deductibles cannot be combined – they must be reached separately.
Who Is Eligible For Hmo Plans
A person must be enrolled in original Medicare to be eligible for an Advantage plan. For the HMO plan, a person must also live in the plans service area.
The Centers for Medicare and Medicaid Services added two special enrollment periods for a person enrolled in an Advantage plan who has a consistent record of poor performance, or is having financial problems and the assets are held by a third party called receivership.
In addition, there are other eligibility requirements for a person with end stage renal disease .
In 2020, people with ESRD are only eligible for an HMO Advantage plan if they enroll in a special needs plan , or previously enrolled in an HMO before the ESRD diagnosis.
From , changes in the regulations mean that a person with ESRD can enroll in an Advantage plan during any valid enrollment period.
You May Like: Does Medicare Cover Long Term Health Care
How Do Medicare Advantage Hmo Plans Work
A health maintenance organization gives you access to a network of doctors and hospitals that you must use in most cases. Some HMO plans require you to get a referral from a primary care physician for hospital care and specialist visits. There are typically limited out-of-network benefits with an HMO plan.
What Is Medicare Part C
A Medicare Advantage Plan is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called Part C or MA Plans, are offered by private companies approved by Medicare.
If you join a Medicare Advantage Plan, the plan will provide all of your Part A and Part B coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage .
Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services . These rules can change each year.
Also Check: How Does Medicare Plan G Work
Is An Hmo Plan Right For Me
There are several factors to take into account when choosing whether an HMO plan is the right option for you and your family. Some key things to consider are:
- Cost of monthly premiums
- Using a PCP vs. choosing your own healthcare providers
- The current health of the people you want to cover
If you are someone who doesnt need a lot of specialist care or dont mind having your care coordinated through a PCP, you can save money with an HMO plan.
When youre ready to purchase an HMO plan, you can visit eHealth.com, opens new window to see which plans are available in your area. Eligible for Medicare? Take a look at Humanas Medicare Advantage HMO plans, opens new window.
And remember, dental care is not covered under medical insurance it requires a separate dental plan. Just like medical insurance, dental insurance comes in HMO and PPO plans. Learn more about Humanas dental HMO plan, opens new window.
Still not sure an HMO is the way to go? You can get more information about the differences between HMOs and PPOs from our HMO vs. PPO comparison chart, opens new window.
Its Also Important To Know How They Are Different For Out
Cigna HMO Open Access
If you get medical care outside of the plans network , those out-of-network services will only be covered if the treatment is considered emergency or urgent care as defined by your health plan documents.
Cigna HMO Point of Service Open Access
If you get medical care outside of the plans network , those out-of-network services may be covered but you will pay more out of pocket and you may need to file a claim.
Also Check: How Much Is Medicare Going Up
What Are Some Benefits To A Ppo Plan
The benefits of a PPO plan may include:
- At least partial coverage for care received outside of the plans network
- No need to use a primary care physician or seek out referrals for specialist care
While some people enjoy having their care coordinated by a primary care physician, others prefer the freedom and flexibility of making their own health care decisions.
Medicare Advantage Hmo Plans
A Health Maintenance Organization plan is a type of Medicare Advantage Plan that provides health care coverage from doctors, other health care providers, or hospitals in the planâs network for certain services.
An HMO plan does not cover emergency care, out-of-area urgent care, or out-of-area dialysis, according to the official U.S. government website for Medicare.
âHMO plans only offer coverage with set provider networks. Generally, these networks are local,â Alice Stevens, Insurance Expert and Senior Editor at Best Company, tells WebMD Connect to Care.
- A small network of providers to choose from
- Less paperwork than other types of insurance plans
- Required referrals from your primary care physician in order to see a specialist
One benefit of a Medicare Advantage HMO plan is simplicityâyou only have to manage one plan instead of many.
âIt can be convenient to have one plan to reference and manage, which a Medicare Advantage HMO Plan makes possible, instead of Original Medicare, where you can end up working with up to four different health plans at once,â Stevens says.
In addition to controlling how much you have to worry about, a Medicare Advantage HMO plan also controls how much of your own money you have to spend. This is known as an âout-of-pocketâ expense.
While healthcare coverage is an important factor in deciding insurance plans, there are also some perks that come with a Medicare Advantage HMO plan for you to consider.
Read Also: When Can You Apply For Part B Medicare
Pros And Cons Of Medicare Hmo Plan Networks
The HMO option is certainly not for everyone. Having a strict network means that you will turn to the same doctor for most of your healthcare needs.
Some plans are called HMO POS, or HMO Point-of-Service plans. These allow you to see providers outside of your network for certain services. If you need to use that benefit, you will usually have to get approval from your plan first, and your provider needs to recommend the other provider.
For example, if your primary care physician suggests that you need to see a nutritionist or other specialist, your PCP can refer you to a nutritionist that he or she trusts and send a request for coverage to your HMO. The con to the HMO option is that your plan can deny your out-of-network coverage.
The pro to selecting one primary physician and having a Health Maintenance Organization is that all of your care is grouped together and managed in one place. Your providers usually work together to manage your care, preventing unnecessary costs.
A licensed agent with Medicare Plan Finder can help you determine if a HMO is right for you. Our agents can help you find the right plan based on your budget and lifestyle needs. To learn more, call 833-438-3676 or contact us here.
If You Choose A Cigna Hmo Open Access Or Cigna Hmo Point Of Service Open Access Plan Its Important To Know The Key Features Of Both Plans:
- You have the option of choosing a primary care provider to serve as your personal health advocate and coordinate your health care. Its recommended, but it is not required.
- You dont need referrals for in-network specialists however if you do see a PCP, they may refer you to a specialist after the initial exam. Cigna may need to pre-certify hospitalizations and other outpatient care, but there’s no paperwork for you when using in-network providers.
Recommended Reading: Does Medicare Pay For Maintenance Chiropractic Care
How To Enroll In Medicare Advantage Hmo Plans
Medicare provides health insurance to people who are 65 years of age or older and younger people who suffer from a disability or end-stage renal disease . Most people will enroll in Medicare during the seven-month Initial Enrollment Period , beginning three months prior to their 65th birthday.
Once you are enrolled in Part A and Part B , you may sign up for an Advantage plan during the Initial Coverage Election Periodwhich is typically the same as your IEP. An Advantage Plan is considered Part C because its a private plan that combines the benefits of both Part A and Part B.
Alternatively, there are several opportunities to enroll:
To find out more about other opportunities throughout the year to make the switch, consult this guide. And if youre still unsure about whether or not you can enroll in a Medicare Advantage HMO plan, you can fill out this Medicare form to check your eligibility.