Medicare Advantage HMO vs. PPO Plans

Medicare Advantage PPO Plans

You have many choices when it comes to Medicare Advantage plans. Among these is the Preferred Provider Organization (PPO) plan. A PPO plan functions uniquely for both the policyholder and healthcare provider, which allows this to be beneficial for everyone involved. It may just be the right plan for you.

What Do PPO Plans Cover?

PPO plans are one of the more flexible choices when it comes to Medicare Advantage plans. With these, you have the combined inpatient and outpatient coverage that Original Medicare offers and many policies include prescription drug coverage to go along with that. 

This gives you coverage for all the services you get while staying in the hospital, and the services you get as an outpatient.

You also get bonus coverage for what’s missing from Original Medicare, including dental, vision, and hearing.

If your specific plan does not offer prescription coverage, you may enroll in Medicare Part D separately.

You also have more freedom. Despite the plan favoring certain physicians within your coverage network, you can get out-of-network coverage for services or treatments you get in any healthcare facility that accepts Medicare. Most Medicare Advantage plans do not have this feature.

How Do They Work?

When you enroll in a PPO plan, you are assigned a coverage network. The extent of coverage depends on the specific healthcare professional operating within the network. Your greatest discounts will be from the preferred providers.

It may seem counterintuitive for the preferred providers to charge so little, but from the healthcare provider’s perspective, he or she is building a patient base. The provider in the network has made a contract with Medicare in order to facilitate this.

Unlike other policies, PPO plans do not require you to choose a primary care physician. You also won’t have to get referrals to see specialists.

What Should I Consider?

Medicare Advantage comes with certain limitations. This is an exclusive program. You will not be able to enroll in a Medicare Supplement Plan or have any secondary health insurance to go along with it. In fact, if you join Medicare Advantage while being under an employer group health insurance, you can lose your employer coverage with no way of getting it back.

Who Is This Right For?

PPO plans are for those who have strong preferences for what providers they see. With a PPO plan, you’re getting rewarded for your choices. It’s also good for individuals seeking a plan that optimizes savings and convenience – it’s everything you need under one plan. PPO plans provide a sense of freedom.

Medicare Advantage HMO Plans

One of Medicare Advantage’s most popular plans is the Health Maintenance Organization (HMO) plan. It offers coverage for inpatient, outpatient, and in many cases, prescription medications under the same plan. It’s convenient, reasonably priced, and comprehensive.

What Do HMO Plans Cover?

HMO plans offer the combined coverage of Medicare Part A, B, and D. It will help cover your hospital and other inpatient facility costs. This includes your room and board, medications, and meals.

This also translates to outpatient treatments and services, even those that Original Medicare omits from its plan (i.e. dental, vision, and hearing). That includes your screenings and exams, as well as immunizations and durable medical equipment.

Prescription coverage varies from one plan to another, as Medicare Advantage comes through private insurance only. Your coverage is according to a formulary, or list, of medications that your plan covers.

If your particular HMO plan does not provide prescription coverage, you can enroll in a separate Medicare Part D plan.

How Do They Work?

When you sign up for an HMO plan, your coverage will be effective within a provider network. You will only be able to get coverage from providers who accept your specific policy. Just because a healthcare professional accepts Medicare does not mean he or she will accept your HMO policy.

You will need to choose a primary care physician, and you’ll need referrals when you need to see specialists. The primary care physician will coordinate the direction of your medical care.

Out-of-network providers may refuse to treat you in a non-emergency situation, even if you have gotten treatments from them in the past.

However, you do have the option to join a modified form of an HMO, known as the HMO Point-of-Service (HMOPOS). This is a way to circumvent the network limits, as this plan offers out-of-network benefits.

What Should I Consider?

As is the case with other Medicare Advantage plans, HMOs come with restrictions. You won’t be able to have a Medicare Supplement in addition to your plan. You also cannot have an HMO plan alongside an employer group health plan. Doing so can cause you to lose employer coverage, and possibly no way to recover your group health plan.

Who Is This Right For?

HMOs are great for anyone interested in Medicare Advantage. Its comprehensive coverage makes it one of the most appealing choices in Medicare. While the restricted network may seem like a limitation, it can also help with familiarity, giving providers a chance to make continuous improvements in treating your conditions. In the end, an HMO can contribute to a longer, fuller life while keeping the money in your pocket.

Get The Plan That Fits Your Preferences

With Peritia Advisors, you’ll be working one-on-one with experts devoted to excellent service. We settle for no less than the best because we believe you deserve a plan that enables you to see the healthcare professionals you prefer at the lowest possible expense. Give us a call today to learn more about what we can do for you.

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