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Health & Wellness / Medicare Toolbox / Your Medicare Advisor

Medicare HMO Plans vs. Medicare PPO Plans: What’s the Difference?

medicare form enroll plansThere are many different types of Medicare Advantage Plans (Part C). When a client is enrolled in a Medicare Advantage Plan, benefits are provided through a Medicare-approved private insurance company. Two of the most common plans are Medicare HMO’s and Medicare PPO’s.

A Medicare Advantage HMO plan offers some of the following features:

  • Contracted network of doctors and hospitals
  • Must choose a primary care physician
  • Must use network providers for covered services
  • Most plans require a referral to see an in-network specialist
  • May include drug coverage depending on the plan selected
  • Covers emergency care received from any provider

A Medicare Advantage PPO Plan offers some of the following features:

  • Contracted network of doctors and hospitals
  • Many plans do not require you to select a primary care physician
  • Coverage for in-network and out-of-network providers (may pay more for out-of-network)
  • Most plans do not require a referral to see a specialist
  • May include drug coverage depending on the plan selected
  • Covers emergency care received from any provider

As you can see, there are key differences between Medicare HMO plans and Medicare PPO plans. Remember—everyone’s needs are different, and you are the best judge of which coverage would work best for you.

 

If you have any questions please call AMAC’s Medicare Department to speak to one of our Trusted, Licensed Insurance Agents

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Read more articles by Melanie Recchion

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HAM

I had a PPO the 1st couple of years after I retired but switched to an HMO after Medicare started charging an additional premium each month for the PPO. I have the same insurance company as with the PPO so my doctors remained in my HMO plan. The PPO gives you more freedom by not having to get referrals for specialists but you still have to use doctors in the network or it will cost you more out of your pocket. Most plans whether PPO or HMO plan will pay less to the doctor if you use one OUTSIDE the network but “may” pay more on a PPO, however it probably won’t be much more. Maybe the difference of 60% under the PPO rather than 50% under the HMO. The balance is your responsibility. The key is to understand your plan before you choose one. Once the deadline has been… Read more »

Ken

Why not stop the confusion,one plan for all. no co-pay, no referrals, any doctor and cut the crap of the high prescription costs. just have the meds included in the plans. Get on the car insurance companies and lower our cost. they have been ripping us off forever. Get on the banks for their high credit card rates and think they are doing you a favor for their banking with them and having their high rated cards with bullshit perks. spend more for points. like $500.00 for $5.00. Get on the cable and dish TV companies..the average person is paying $1200 to $2400 to watch TV. Insane. The cell phone companies branched out and big competitions arose. Look at the lower choices we all have because of it. So we all have to get on these hotshot rule and law makers together and protest. One place is at the voting… Read more »

linda Zerangue

How to find an insurance agent that medicare pays to help understand the plan we have and to make decision on whether to switch our plans.

Frank

One thing not mentioned, if one has a Medicare Advantage plan, they are not allowed to purchase supplemental insurance. I can have plain Medicare and purchase a supplement and then pay nothing more out of pocket. But with the Medicare Advantage, I’m always stuck with co-pays that turn out to be a lot more than a premium for a supplemental seems to cost. The same goes for drugs that are included in the Medicare Advantage plan.

Rick

I thought President Trump signed a bill allowing cross-state-border competition for health plans, but there seems nothing about it in the news or otherwise. Is that true? When will it become active? Competition will surely help the Medicare situation. I live in a state where only two providers offer Medicare-related coverage. The advantage plans all have high co-pays that are killing us. Is help on the way?

Diane

I just learned about AMAC and joined. I have had Kaiser Sr. Advantage for years and recently the copays have become ridiculous. It seems that every copay lately for any test is surgical. They need me to repeat a test I had 4 years ago. The first one was done in an office with normal copay. They closed the department and now the test is done in an office in a hospital. Still not surgical. But because it’s done at a hospital now, they are charging a surgical copay. I called and they said that it has nothing to do with the procedure but the location where it is done! I’m dumping them and would love to hear how some of the companies with AMAC are treating their customers.

Thanks!

Scottar

As far as I’m concerned medicare is too restricted and really doesn’t offer the coverage a private plan would. Too much bureaucracy of course in the works. Medicare should be just for the poorest and just for basic insurance. The government wasn’t setup to provide healthcare.

linda Zerangue

How to find a medicare insurance agent?

Ken

You can also get free advice from your states medicare insurance office, by phone, by mail or in person at a medicare seminar
put on by your states insurance office. So, call your states insurance office or check their webpage for seminars in your zip code.
A wonderful book that explains many intricacies of Medicare is “Medicare for Dummies.” It is loaded with information about all aspects of Original/Traditional Medicare vs Medicare Advantage, plus Medigap Plans and Part D drug plans. I am finishing up the book right now as I turn 65 before the end of the year and will take advantage of all the resources they provide in the book, in addition to working with an insurance agent.