WHAT IS A MEDICARE ADVANTAGE PLAN?

A Medicare Advantage plan (also known as “Part C” or “MA Plan”) is a privately run insurance provider that covers Medicare benefits paid for by Original Medicare. These companies are approved by Original Medicare and covers everything offered by Medicare Part A and Medicare Part B.

WHAT IS AN HMO?

HMO stands for Health Maintenance Organization. HMOs have their own network of doctors, hospitals, and other healthcare providers who have agreed to accept payment at a certain level for any services they provide. In essence, these providers have agreed to lower their rates for participants while maintaining quality care. This allows the HMO to keep costs in check for its members.

In most HMOs, you can only go to doctors, other health care providers, or hospitals in the plan’s network, except in an urgent or emergency situation. You may also need to get a referral from your primary care doctor for tests or to see other doctors or specialists. Your costs will be covered only if you see an in-network provider. There is no guarantee for health care costs to be covered if you see an out-of-network provider.

WHAT YOU SHOULD KNOW ABOUT HMOs

  1. Lower Cost. Because of the agreed-upon payment level HMOs make with healthcare providers, an HMO usually offers lower monthly premiums than other types of insurance plans, including other types of Medicare Advantage Plans. HMOs also tend to have lower copays and coinsurance, which helps make them more affordable. However, be aware that even though costs are generally lower with an HMO, they don’t cover any out-of-network care, except in a true emergency.
  2. Choice of providers. With an HMO, you must choose a primary care physician (PCP) from a network of local healthcare providers when you join. This is the doctor you will see whenever you need medical care. Your PCP will be the provider with the best overall picture of your health and will be the one to coordinate any additional care you might need. This limits your choices.
  3. Referrals. If you were to need the care of a specialist, you would most likely need a referral from your PCP. This means you would first have to see your PCP who would determine whether or not you need to see a specialist. And the specialist would have to be within the HMO’s network, which further limits your options.
  4. Restrictions. With an HMO plan, there are typically more restrictions for coverage than other plans, such as allowing only a certain number of office visits per year, tests, or treatments.

IS AN HMO RIGHT FOR YOU?

  • If you are overall in good health and you only see the doctor for preventative care such as regular annual check-ups or for immunizations or flu shots, then an HMO is probably a good choice for you.
  • If you don’t particularly care who your doctor is, then an HMO may be for you.
  • If you don’t need to see a lot of specialists, then an HMO may be for you.

WHO SHOULD NOT CHOOSE HMOS?

If you want to keep your current doctor and they are not in network, then a PPO (Preferred Provider Organization) Plan would be the better, more cost-efficient option.

HOW DOES AN HMO WORK?

Most Medicare Advantage Plans have copays or coinsurance and an annual deductible, including HMOs.

FACTORS TO CONSIDER WHEN DECIDING IF AN HMO IS FOR YOU

  • Cost of monthly premiums
  • Out-of-pocket costs
  • Using a PCP, which limits your options, versus choosing your own healthcare providers
  • The current health of the people you want to cover
Question HMO Health Maintenance Organization PPO Preferred Provider Organization
How much will this plan cost? Lower cost
HMO plans typically have lower monthly premiums. You can also expect to pay less out-of-pocket for medical services.
Higher cost
PPOs tend to have higher monthly premiums in exchange for the flexibility to use providers both in- and out-of-network without a referral. Out-of-pocket medical costs can also run higher with a PPO plan.
Do I have to use a Primary Care Physician (PCP)? YES
With most HMO plans, all of your healthcare services are coordinated by your designated Primary Care Physician (PCP).
NO
A PPO plan does not require you to select a PCP. You can receive care from any doctor you choose, however you will save money by choosing a healthcare provider within your network.
Do I have to get referrals to use another doctor? YES
With an HMO, you must first schedule an appointment with your PCP and he/she will provide a referral to an in-network specialist.
NO
PPO plans do not require referrals for any services.
If I have a doctor or specialist who is out-of-network, will I still be able to see them and have the costs covered? NO
HMOs don’t offer coverage for care from out-of-network healthcare providers. The only exception is for true medical emergencies.
YES
With a PPO, you have the flexibility to visit providers outside of your network. However, visiting an out-of-network provider will include a higher fee and a separate deductible.
Will I need to file claims? NO
Since HMOs only allow you to visit in-network providers, it’s likely you’ll never have to file a claim. This is because your insurance company pays the provider directly.
YES
In some cases, you will have to pay a doctor for services directly, and then file a claim to get reimbursed. This is most common when you seek services from out-of-network providers.

Source: https://www.humana.com/all-products/understanding-insurance/hmo-vs-ppo

Dental care is not covered under medical insurance and will require a separate plan. Both HMO and PPO plans offer dental coverage. With HMOs, you can get Medicare prescription drug coverage by enrolling in a Medicare Advantage Prescription Drug plan.

While HMOs are cheaper than PPOs, there are more restrictions in place. The question you need to answer is this: is the cost savings of an HMO worth the restrictions in health care choices you will have? Keep in mind both your current needs and your future needs when deciding whether a HMO is for you.

Are you still not sure an HMO is right for you? Our Medicare Advantage Plan experts at MedicareGov Directory in St. Louis can help. We’ll answer all the questions you may have and help you to understand the complexities of Medicare Advantage Plans, PPOs, and HMOs. Furthermore, we’ll evaluate your unique situation and offer recommendations on HMOs and PPOs and which one is right for you. With so many different options available, we strive to put the customer first in all that we do. Contact us today!