Differences Between HMOs And PPOs In Medicare Advantage Plans

If you choose a Medicare Advantage Plan (Part C) rather than Original Medicare (Part A and B), this plan involves Medicare-approved private insurance companies. This type of Medicare typically includes the same hospital and medical insurance coverage as Original Medicare, but the plan is commonly an HMO (Health Maintenance Organization) or a PPO (Preferred Provider Organization).

There are several differences between HMOs and PPOs. With HMOs, you choose a primary care physician (PCP) from a network of healthcare providers, and insurance coverage is available if you select a provider who is in-network. If you visit a specialist or a special test is needed, the PCP gives you a referral. In addition, if the physician you see is outside of the network, your HMO plan will not pay for the visit or medical services that result from the visit.

PPOs offer more flexibility. While they also have a network, PPOs permit you to see the healthcare provider you prefer without a PCP referral. Depending upon your plan, treatment from an out-of-network doctor or medical care facility might be covered, but coverage is better if you remain in the PPO’s network.

You should also consider the cost of your premium and potential medical costs. HMOs are often easier on your budget but there are more restrictions on them. PPOs are less regimented when it comes to using out-of-network healthcare providers and facilities, but they are more costly. It’s also important to note that most Medicare Advantage plans offer prescription drug coverage (Part D of Medicare).

There are only certain times of the year when you can make changes to your Medicare coverage. Between October 15 and December 7 open enrollment, any person with Medicare can join, switch or get out of a Medicare Advantage Plan. There are also special enrollment periods that let you change your plan under certain circumstances.

When you’re ready to seek advice about Medicare, remember that Tepsick Insurance is here to help. Contact us for assistance in choosing the type of Medicare plan that fits your needs.

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