Medicare HMOs and PPOs, Explained
Medicare - HMOs and PPOs
When counseling Medicare beneficiaries about their options, I'm often asked about Medicare Advantage, Managed Care Plans. The two most common types are HMOs and PPOs.
What are they, what are the differences, costs involved and which one should I choose?
An HMO is a Health Maintenance Organization that was established to contain health care costs and provide a more efficient system. They can provide cheaper health care coverage for the organization as well as the members, by using a tight network of contracted doctors, hospitals, pharmacies and other health care providers. Each member must select, or be assigned to, a Primary Care Physician (PCP), who will provide and manage most of the member's healthcare. The PCP acts as the gatekeeper to other health providers by providing referrals to specialists and other consultants within the HMO's contracted network. Your services may not be covered outside of their network.
A PPO is a Preferred Provider Organization that like an HMO has a network of doctors and hospitals. However, members can go outside of the network for their healthcare. It is best to select a PCP, but you are not required to have one. You can make appointments directly with other providers since referrals are not required. You can use providers outside of the network, but you will be paying a higher cost share. A PPO offers more flexibility and allows members to manage their own care.
Some reasons to select an HMO over a PPO:
I want the lowest cost share.
I only visit my Primary Care Physician once a year and he (or she) is in the HMO's network.
I don't want to manage my own healthcare, which requires me to select specialists and other providers on my own.
I'm relatively healthy and don't require frequent visits to specialists.
Some reasons to select a PPO over a HMO:
A higher cost share is not a problem for you.
Your health condition requires regular visits to specialists or other providers and you don't want to worry about referrals and networks.
You are comfortable managing your own healthcare decisions.
You travel frequently and don't want to worry about rules regarding provider networks.
The costs in a HMO and PPO include a Monthly premium? There are many new HMO's and PPO's that have a "0" monthly premium. There may be an Annual deductible for medical or prescription drug costs before the plan pays. There are Co-pays (a set dollar amount) and
Co-insurance (a percentage you pay) for covered services. There is an Out-of-pocket maximum for the calendar year - which does not include your Co-pays for prescription drugs as well as some other services, and finally there may be a Lifetime Maximum for your care.
After enrolling in a plan, I recommend a plan review every year during the Annual Election Period (AEP) as plan costs and benefits change. For 2013, the AEP was October 15-December 7.
I'm a licensed insurance agent, specializing in Medicare education and options. I can be reached at renkam10@comcast.net, or http://www.FloridaSeniorsInsurance.com.
"Ren?‚©e Lempert is not affiliated with or endorsed by the U.S. Government or the Federal Medicare program".
When counseling Medicare beneficiaries about their options, I'm often asked about Medicare Advantage, Managed Care Plans. The two most common types are HMOs and PPOs.
What are they, what are the differences, costs involved and which one should I choose?
An HMO is a Health Maintenance Organization that was established to contain health care costs and provide a more efficient system. They can provide cheaper health care coverage for the organization as well as the members, by using a tight network of contracted doctors, hospitals, pharmacies and other health care providers. Each member must select, or be assigned to, a Primary Care Physician (PCP), who will provide and manage most of the member's healthcare. The PCP acts as the gatekeeper to other health providers by providing referrals to specialists and other consultants within the HMO's contracted network. Your services may not be covered outside of their network.
A PPO is a Preferred Provider Organization that like an HMO has a network of doctors and hospitals. However, members can go outside of the network for their healthcare. It is best to select a PCP, but you are not required to have one. You can make appointments directly with other providers since referrals are not required. You can use providers outside of the network, but you will be paying a higher cost share. A PPO offers more flexibility and allows members to manage their own care.
Some reasons to select an HMO over a PPO:
I want the lowest cost share.
I only visit my Primary Care Physician once a year and he (or she) is in the HMO's network.
I don't want to manage my own healthcare, which requires me to select specialists and other providers on my own.
I'm relatively healthy and don't require frequent visits to specialists.
Some reasons to select a PPO over a HMO:
A higher cost share is not a problem for you.
Your health condition requires regular visits to specialists or other providers and you don't want to worry about referrals and networks.
You are comfortable managing your own healthcare decisions.
You travel frequently and don't want to worry about rules regarding provider networks.
The costs in a HMO and PPO include a Monthly premium? There are many new HMO's and PPO's that have a "0" monthly premium. There may be an Annual deductible for medical or prescription drug costs before the plan pays. There are Co-pays (a set dollar amount) and
Co-insurance (a percentage you pay) for covered services. There is an Out-of-pocket maximum for the calendar year - which does not include your Co-pays for prescription drugs as well as some other services, and finally there may be a Lifetime Maximum for your care.
After enrolling in a plan, I recommend a plan review every year during the Annual Election Period (AEP) as plan costs and benefits change. For 2013, the AEP was October 15-December 7.
I'm a licensed insurance agent, specializing in Medicare education and options. I can be reached at renkam10@comcast.net, or http://www.FloridaSeniorsInsurance.com.
"Ren?‚©e Lempert is not affiliated with or endorsed by the U.S. Government or the Federal Medicare program".
Source...