HMO PLANS

Medicare HMO plans are a popular option in America. According to the Kaiser Family Foundation, approximately 30% of Medicare beneficiaries are enrolled in some type of Medicare Advantage plan.

Medicare HMOs are common because of the lower premiums they often offer. In some plans, that premium may be as low as $0. However, you must still be enrolled in and paying for Medicare Part B. You usually must also treat with in-network providers except in the case of an emergency.
 

In HMO Plans, you generally must get your care and services from providers in the plan's network, except:

• Emergency care
• Out-of-area urgent care
• Out-of-area dialysis

In some plans, you may be able to go out-of-network for certain services. But, it usually costs less if you get your care from a network provider. This is called an HMO with a point-of-service (POS) option.

 

In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want Medicare Prescription Drug Coverage (Part D), you must join an HMO Plan that offers prescription drug coverage.

In most cases, yes, you need to choose a primary care doctor in HMO Plans.

In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don't require a referral.

• 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's network, 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. 

 

What is a Medicare HMO?

Medicare Health Maintenance Organizations (HMOs) are private plans that the federal government pays to administer Medicare benefits. Like all Medicare Advantage Plans, HMOs must provide you with the same benefits, rights, and protections as Original Medicare, but they may do so with different rules, regulations, restrictions and costs. Some HMOs offer additional benefits, such as vision and hearing care.

Eligibility and Costs Basics

You must have both Parts A and B to join a Medicare HMO. Generally, you will continue paying your Medicare Part B premium, though some HMOs will pay part of this premium. Some HMOs may charge an additional premium, on top of your Part B premium. If you want Part D coverage, you will receive it through your HMO. Plans may charge a higher premium if you also have drug coverage. Note: If you join a Medicare Advantage Plan and you want Part D coverage, you must receive coverage from your plan. You cannot enroll in stand-alone Part D coverage unless you join a Medicare Savings Account (MSA) or a Private Fee-For-Service (PFFS) plan that does not offer prescription drug coverage.
Typically, you cannot have an HMO if you have ESRD (End Stage Renal Disease), unless:

• You join a Special Needs Plan(SNP) which is an HMO plan that specifically takes beneficiaries with ESRD
• Or, you were enrolled in an HMO prior to developing ESRD and you choose to stay in that HMO

Note: If you remain enrolled in an HMO after developing ESRD and the plan leaves your area, you have a Special Enrollment Period (SEP) to enroll in another HMO in your area.

Benefits Access Basics

Once you have joined an HMO, you should receive a benefit card from your plan. You will use your HMO benefit card instead of your Medicare card when you go to the doctor or hospital.

In most HMOs, you must see in-network providers to receive coverage, unless you need emergency medical treatment. Some HMOs offer a point-of-service (POS) option, which allows you to go out of network for certain services. In these cases, you will be covered but usually at a higher cost.
 

In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don't require a referral.

In most cases, you don't have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.

You don't have to get a referral to see a specialist in PFFS Plans.   

In most cases, you have to get a referral to see a specialist in SNPs. Certain services don't require a referral, like these:

• Yearly screening mammograms
• An in-network pap test and pelvic exam (covered at least every other year)

 

In most cases, yes, you need to choose a primary care doctor in HMO Plans.

 

You don't need to choose a primary care doctor in PPO Plans.

You don't need to choose a primary care doctor in PFFS Plans. 

 

In most cases, SNPs may require you to have a primary care doctor. Or, the plan may require you to have a care coordinator to help with your health care.

 

NOW THAT YOU KNOW MORE ABOUT MEDICARE ADVANTAGE PLANS, PLEASE REMEMBER THESE IMPORTANT TIPS BEFORE YOU MAKE ANY DECISION TO JOIN A MEDICARE ADVANTAGE PLAN

One of the main reasons people join a Medicare Advantage Plan is that they are attracted to the advertising talking about the "EXTRA BENEFITS" not offered by Original Medicare.  But, what they do not understand that these benefits are not always how they are advertised.  For example: A $2,000 Dental Benefit is usually broken down into 4-$500 Benefits each Quarter. And, the unused amounts do not roll-over to the next quarter,  Medicare Advantage plans are well known in the industry for these tactics.  Please, please, please read the FINE PRINT of any plan.  You can find out more details on every plan by reading the Summary of Benefits and the Explanation Of Coverage sections printed in every Medicare Advantage Plan.

Every Medicare Advantage Plan has a mandatory MOOP or Maximum-Out-Of-Pocket limit.  This means that once you reach your limit, all of your health bills will be paid for by your plan for the remainder of the year.  That is great, but EVERY MOOP is at least $1,000 - $3,500 more that what it would cost to have better coverage with Original Medicare and a Medicare Supplement.

NO Medicare Advantage Agent will ever tell you that you will always have a 20% Co-Insurance that you have to pay for for Cancer Treatments.  Even if you hit your MOOP, you still have to pay 20%.  Average Rounds of Chemotherapy and Radiations treatments cost between 10K - 15K, that is a lot of potential Out Of Pocket expenses you are always on the hook for with a Medicare Advantage plan.

Your plan may require you to get 2-3 or more 2nd opinions for treatments.  Remember, these plans are "For Profit", their job is to string you along until the plan year is over so they do not have to pay out large sums of money if they do not have to.  It is sad, it is not fair, but; its the truth.

The US Government pays every Medicare Advantage Insurance company $1,000 each month for every Medicare Advantage Member they have.Ask yourself, if they get 12K per year from the Government, why are they "Nickel and Diming" their plan members to death?

The last thing that is important for you to know is that if you join a Medicare Advantage PPO plan, there is no guarantee you can see any doctor you choose.  Yes, you have the right to see if they will see you, but remember, they do not have to.  And, why would they agree to taking less money from you when they do not have to accept your plans rates.  The honest cold hard truth is if they wanted to be a doctor in your plans network, they would.  The fact that they are not in your plans network should tell you all you need to know.