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Medicare HMO vs. PPO plans

If you are considering a Medicare advantage plan, you will need to weigh Medicare HMO vs. PPO plans.  The first thing we need to do is explain that HMO stands for Health Maintenance Organization plans.   On the other hand, PPO stands for Preferred Provider Organization plans. Each of these plans provide its own set of benefits.  The plan you choose will impact your healthcare experience.

Understanding the Basics:

Medicare HMO and PPO plans operate within the broader framework of Medicare.  Both types of plans cater to the healthcare needs of Medicare beneficiaries.  Although the share the goal of providing essential healthcare coverage, they function differently in terms of network flexibility, cost structure, and coverage options.

Medicare HMO Plans:

HMO plans typically require beneficiaries to choose a primary care physician (PCP).  The PCP coordinates their care as well as provides referrals to specialists within the HMO network. This approach supports a structured healthcare management system.  This ensures a comprehensive and coordinated approach to treatment.

Additionally, Medicare HMO plans often come with low premiums and lower out-of-pocket costs when compared to some PPO plans. They also may provide some benefits such as a Part B giveback that PPO plans typically do not. However, the trade-off for these cost savings is the restricted network access.  This may limit the choice of healthcare providers and facilities.  In most cases HMOs do not cover medical care received outside the HMO network, except in emergencies or urgent care situations.

Medicare PPO Plans:

On the other hand, PPO plans offer more flexibility in choosing healthcare providers and facilities.  This allows beneficiaries to seek treatment both in and out of the PPO network. Although there is a network of preferred providers, beneficiaries can still access care from out-of-network providers.  It is important to note; out of network services will have a higher cost to beneficiaries than in-network.

In general PPO plans may have a higher premium and greater out-of-pocket costs when compared to HMO plans. Nonetheless, the flexibility to see specialists or visit healthcare facilities without referrals can be advantageous.  This is helpful for those who require specialized care or have established relationships with trusted providers.

Key Considerations for choosing a plan:

When deciding whether an HMO or PPO plan best suits your needs, there are several key factors to consider:

1. What are your healthcare needs – Think about your healthcare requirements, this includes how often you require the care of a specialist.  You may need to go out-ot-network for some providers.
2. Cost Considerations – Compare the premiums, deductibles, and co-pays associated with both plans. Do not discount potential out-of-network costs for either plan.
3. Provider Network – Research the size and quality of the provider network. It is important to consider the availability of preferred doctors and specialists within each plan.
4. Network area – If you frequently travel or reside in multiple locations throughout the year, it is important to consider the geographic area of coverage available.
5. Prescription Drug Coverage – It is very important to research the prescription drug coverage provided by each plan.  This is imperative if you require regular medications.

Making the Right Choice:

Ultimately, the decision between a Medicare HMO and PPO plan hinges on your individual healthcare needs, financial circumstances, and preferences.

While HMO plans offer cost-effective, structured care within a limited network, PPO plans provide greater flexibility at a higher cost. Carefully evaluate your healthcare priorities and compare the specifics of each plan to make a well-informed decision.

It is a good idea to consult with a trusted healthcare advisor.  A licensed Medicare agent can help you review plan documents thoroughly and find the best option for you. A well informed agent can also answer your health coverage questions and is available to you when you need them.

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Pros And Cons Medicare Advantage

With the Annual Enrollment Period just around the corner, agents need to brush up on all kinds of knowledge and regulations to better serve their clients in the coming months. Let’s look at the pros and cons of Medicare Advantage plans.  Here’s a quick breakdown of the benefits and drawbacks of choosing a Medicare Advantage plan:

Pros And Cons Medicare Advantage – Pros

• Medicare Advantage plans (also known as Medicare Part C) typically have cheaper premiums than Original Medicare. This can be a good choice for beneficiaries who need lower monthly premiums or out-of-pocket costs.

• Medicare Advantage plans typically include drug coverage. This is not the case with Original Medicare.

• There is an in-network out-of-pocket maximum for plan holders, which means that a beneficiary will not pay more than $8,300 a year for healthcare.

• Medicare Advantage plans often come with perks, such as some vision, hearing, and dental services that do not come with Original Medicare plans. In some cases, they even include gym membership stipends or preventative chiropractic care.

Pros And Cons Medicare Advantage – Cons

• Because there is a network of healthcare providers for each Medicare Advantage plan, beneficiaries are limited to the providers that are in-network. This means that they can use only certain hospitals, providers, and services in their area.

• There is an approval process for some services and prescriptions, like preauthorization on seeing in-network specialists. Many services do require referrals in order to be covered by the plan. Original Medicare does not include this restriction.

• The network of providers may change throughout the beneficiary’s plan, which may lead to inconsistencies in their doctors and providers being covered.

• Costs are based on how often the beneficiary sees a doctor. The monthly premiums in Medicare Advantage plans are low or even free.  Co-pays, coinsurance, and deductibles contain most of the cost. This means that a health emergency or expensive medical care could cost the beneficiary more with a Medicare Advantage plan than with an Original Medicare plan.

With this information, agents will be able to better help their clients.    Better evaluate if a Medicare Advantage plan is right for them.

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Get Started With Medicare

Medicare is its own universe  with its own jargon, terms, rules, and regulations. This can be intimidating, especially for those of us just starting out. However, signing up for Medicare is a vital step in making sure that you and your family have access to the essential healthcare you need in your golden years. Beware of Medicare scams!   Protect your Medicare ID and enrollment information.    Read on to learn how to get stared with Medicare.

 Learn the Basics

Original Medicare has two parts: Part A and Part B. Part A is hospital insurance, and Part B is medical insurance. Within these two parts, many of the basic health care you will need is covered. There is also Part D, which are prescription drug plans that are purchased separately. Medigap, or Medicare Supplemental Insurance, refers to additional coverage purchased from private insurance carriers that helps pay for the out-of-pocket costs of Medicare. Another name for Medicare Part C is  Medicare Advantage.   Part C is an alternative to Original Medicare.  Private insurance companies offer MAPDs.   The federal government does not offer these plans. These are bundled plans that usually include hospital, medical, and prescription coverage.  You must enroll in Medicare to qualify for one of these plans.

Prepare to Sign Up – Enroll

Get started with Medicare.   Most become eligible at age 65. And, promptly sign up.  Individuals receiving benefits from Social Security are automatically enrolled in Part A of Original Medicare.   Part A is hospital insurance. When they sign up for Social Security benefits, they have a choice about whether or not to enroll in Part B (medical insurance). Therefore, individuals not receiving Social Security benefits, must enroll in Part A.  Enrollment is not automatic for these persons. Here are the easiest ways to sign up:

• Online, at Social Security. The website is the easiest, fastest way to sign up and access any financial help you may qualify for.

• Call Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778.

• You can contact your local Social Security office.

• If you or your spouse worked for a railroad, call the Railroad Retirement Board at 1-877-772-5772.

Regardless of method used to get stared with Medicare,  beneficiaries receive a welcome packet.     The welcome packet includes a Medicare card.   After enrollment, it takes about   2-3 weeks for the card to arrive.

Using Medicare

New enrollees will receive their Medicare card and start their coverage. It is a good idea to keep the Medicare card private, and only share it with medical professionals if necessary, as there are many scams around filing false claims to Medicare. The majority of doctors and service providers in the nation accept Medicare – about 93%. The most commonly excluded health care professionals, those who opt out of Medicare assignment, are psychiatrists and mental health practitioners, as well as pediatricians. It may also be helpful to give Medicare permission to share your information with someone you trust.  They can help if there is ever a medical emergency and you are unable to discuss treatment.

With these three simple steps, you will be well on your way to using Medicare successfully.

After Enrollment

The rise of automated and exclusively-online enrollment means that it can be easier to use technology to scam the unsuspecting.  Beware of Medicare scams!   Protect your Medicare ID and enrollment information. Medicare beneficiaries should always remember that Medicare will not reach out to beneficiaries via call or email unless they are answering their inquiry. Medicare will also never offer free gifts, medical equipment, or any other service for free.

Additionally, beneficiaries on an advantage plan do not need to show their Medicare card to providers.   Therefore, best if this card remains in a secure location not on them.

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Medicare HMO vs PPO

Choosing an insurance plan can be a minefield. There are many decisions to make in order to find a plan with the best coverage that fits an individual’s needs. One of these decisions is which type of plan makes the most sense: Medicare HMO vs PPO?

HMO

An HMO is a Health Maintenance Organization. The organization has a network of doctors, hospitals, and other healthcare providers. They provide services for a specific payment, which allows the organization to maintain lower costs for its members. Costs and choices are two factors that beneficiaries tend to appreciate HMOs versus other healthcare plans. HMOs are often less expensive with lower monthly premiums. However, they require referrals to use doctors other than the beneficiary’s primary care physician. HMOs do not offer coverage for out-of-network providers except for in the case of a true medical emergency.

PPO

PPOs are Preferred Provider Organizations. These offer a network of healthcare providers to use for the beneficiary at a certain cost. With a PPO, a beneficiary can choose to receive care from any healthcare provider regardless of if they are in the network. While PPOs do have higher monthly premiums, they offer flexibility that an HMO does not. They do not require that a beneficiary has a primary care physician or that they get referrals to see any healthcare provider. If a beneficiary wants to see a healthcare provider outside of the PPO network, they may have to pay the doctor upfront and then file a claim to get reimbursed from their insurance plan.

Insurance decisions must take a lot of factors into consideration. In general, however, an HMO may be a better choice for beneficiaries that need lower out-of-pocket costs. They tend to have lower deductibles and make sense if the beneficiary does not mind using a primary care physician as their primary healthcare provider for all of their needs. A PPO may be a better choice for beneficiaries who already have a healthcare team that they would like to keep, as well as the flexibility to see specialists at will. They can expect to pay higher costs for this flexibility.

Medicare HMO vs PPO: What’s the Difference?

Choosing an insurance plan can be a minefield. There are many decisions to make in order to find a plan with the best coverage that fits an individual’s needs. One of these decisions is which type of plan makes the most sense: an HMO or a PPO?

An HMO is a Health Maintenance Organization. The organization has a network of doctors, hospitals, and other healthcare providers. They provide services for a specific payment, which allows the organization to maintain lower costs for its members. Costs and choices are two factors that beneficiaries tend to appreciate HMOs versus other healthcare plans. HMOs are often less expensive with lower monthly premiums. However, they require referrals to use doctors other than the beneficiary’s primary care physician. HMOs do not offer coverage for out-of-network providers except for in the case of a true medical emergency.

PPOs are Preferred Provider Organizations. These offer a network of healthcare providers to use for the beneficiary at a certain cost. With a PPO, a beneficiary can choose to receive care from any healthcare provider regardless of if they are in the network. While PPOs do have higher monthly premiums, they offer flexibility that an HMO does not. They do not require that a beneficiary has a primary care physician or that they get referrals to see any healthcare provider. If a beneficiary wants to see a healthcare provider outside of the PPO network, they may have to pay the doctor upfront and then file a claim to get reimbursed from their insurance plan.

Deciding Between the Two

Insurance decisions must take a lot of factors into consideration. In general, however, an HMO may be a better choice for beneficiaries that need lower out-of-pocket costs. They tend to have lower deductibles and make sense if the beneficiary does not mind using a primary care physician as their primary healthcare provider for all of their needs. A PPO may be a better choice for beneficiaries who already have a healthcare team that they would like to keep, as well as the flexibility to see specialists at will. They can expect to pay higher costs for this flexibility.

Medicare Agents

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Medicare Advantage  Enrollment Trends

There are continually increasing populations of people who become eligible for Original Medicare and Medicare Advantage plans each year in the United States. Since 2006, the amount of enrollees for Medicare Advantage plans has grown steadily.  In 2022, more than 28 million people are enrolled in a Medicare Advantage plan, accounting for nearly half or 48 percent of the eligible Medicare population. This number also accounts for nearly half of the federal Medicare spending.  Let’s explore the Medicare Advantage enrollment trends.

In 2022, the average Medicare beneficiary has access to nearly 40 Medicare Advantage plans, which is the largest number of plans available in over a decade. This looks like 2.2 million new beneficiaries between 2021 and 2022, which is an eight percent increase in enrollees.

Employer Group Versus Individual Plans

In 2022, of the 28.4 million beneficiaries enrolled in Medicare Advantage.   The smallest percentage were enrolled in special needs plans, at a mere 16%. The next smallest group of beneficiaries was those enrolled in union-sponsored or employer-offered Medicare Advantage plans.   These account for 18% of the total. The largest group of beneficiaries by far is those in individual plans –  open for general enrollment.   This group makes up 66% of the 28.4 million beneficiaries. That is about two thirds of this group, or approximately 18.7 million people. Since 2021, that is an increase of about 1.3 million enrollees. However, the share of those in individual plans open for general enrollment has not increased.  It remains steady at about two thirds of the enrollment since 2018.

Medicare Advantage Plans By State

The share of Medicare beneficiaries who are enrolled in Medicare Advantage Plans varies greatly by state and has a very wide range of percentages across the country. However, in 25 of the states, at least half of those eligible for Medicare Advantage plans are enrolled in them. The more rural a state is, the more likely it is to have lower funding for Medicare and lower enrollment in Medicare Advantage plans. South Dakota, North Dakota, Wyoming, and Arkansas are the states with the lowest Medicare Advantage enrollment, which is less than twenty percent, or fewer than one fifth of eligible beneficiaries. Puerto Rico, on the other hand, has the highest percentage of enrolled beneficiaries, with 93% of Medicare beneficiaries also enrolled in a Medicare Advantage plan. This is largely thought to be due to policy choice, as many people in Puerto Rico are dually enrolled automatically in Medicare and Medicaid.

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History of Medicare Advantage

The origins of Medicare Advantage,  also known as Medicare Part C, are in the 1970s.  Medicare is ever evolving.   Let’s discuss the high level history of Medicare Advantage.  The details are consistently redefined even today.

In a nutshell,  the greater part of the  3 decades following the 1970s bring beneficiaries major changes.

Balanced Budget Act of 1997

The Balanced Budget Act of 1997  established the new Part C of Medicare – Medicare + Choice.  Medicare Choice is an early version of what we know today as Medicare Advantage.  Additionally, the Balanced Budget Act aimed to earn federal savings within the Medicaid system in three areas. The gross federal Medicaid savings comes from three sources: Repeal of minimum payment standards from hospitals, nursing homes, and community health centers.

History of Medicare Advantage – Medicare Modernization Act

In 2003,  the Medicare Modernization Act passed.  Medicare Part D, prescription drug coverage and benefits, are established.  At this time, Medicare Choice Plans are officially renamed Medicare Advantage Plans. Before 2003, Medicare offered no prescription benefits or coverage. Because of this new coverage, beneficiaries can recently get all of their medical needs covered in one place, with one cohesive plan, and with one convenient ID card.

Privatized insurance companies begin to offer Medicare Advantage plans.  These companies contract with the United States government to provide plans that fit strict guidelines. MAPDs typically cover the same benefits as Original Medicare, in addition to extra coverage including out-of-pocket maximums, some minimal dental coverage, some hearing coverage, and, in most cases, prescription drug coverage.  Private insurance companies offer Medicare Advantage (MA) plans.  Insurance carriers contract with the program. Medicare Advantage plans provide hospital, outpatient, and, usually, prescription drug coverage.   These plans supplant benefits under Medicare parts A, B, and D.   However, plans are risk-based plans.   Advantage plans are not universal plans covered by the federal government.  And, there is variation in the quality and quantity of benefits that purchasers receive. They are ubiquitous, though, with over 98% of beneficiaries having had access to privatized plans in 2017.

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What is a Medicare Advantage Plan

Original Medicare includes benefits for Part A (hospitalization) and Part B (doctor visits).  However, not all of a beneficiary’s needs may be satisfied.   (Click here to learn 5 things that are not covered.)  A Medicare Advantage Plan, also known as Medicare Part C or MAPD, can be an effective and financially smart way to ensure that senior citizens have the medical coverage they need going into their golden years.

While not part of the original federal health plan, Medicare Part C became law in 1982. The way it works is that the federal government pays private insurance companies a specific amount of money per person to bundle the original Medicare benefits. Many companies also add prescription drug coverage, or Medicare Part D, in their advantage plans. Some of these plans cover additional services than original Medicare, making them a smart choice for many senior citizens.

Because many Medicare Advantage plans work like private insurance plans, the options for them include:

• Health maintenance organization plans (HMOs)

• Preferred provider organization plans (PPOs)

• Private fee-for-service (PFFS)

Because of their connection to the federal plan, Medicare usually sets the fee for both the provider and the individual enrollee. But, for a PFFS plan, the private insurance company sets those fees. Medicare Advantage plans must follow Medicare rules and guidance from the federal government, though each private company can have different out-of-pocket costs or access to services. In addition, insurance companies can, and do, change the rules of their Medicare Part C (Advantage) plans each year.

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Medicare Advantage Plans Connecticut 2014

Below we have provided some information about Medicare Advantage Plans Connecticut 2014.

Medicare Advantage plans have become the go to option for seniors.  Advantage plan enrollment has increase from a little over 5 million in 2004 to over 13 million in 2013.  While the number of people enrolling has increased, the value of the benefits inherent in Advantage plans has been steadily declining year over year.

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There are only certain times when you can enroll/dis enroll or change a Medicare Advantage plan. Note that Medicare Advantage plans are sometimes called Medicare Part C or an MAPD plan.   There is a general period when someone turns 65 in which they can enroll.  This time frame is 3 months before the month they turn 65, the month they turn 65 and three months after they turn 65.  There is also the AEP period during which current members can make any type of plan change. This period runs from October 15th to December 7th every year. During this time, an application can be put in to make a change for a January 1 effective date.   The last type of period is the SEP period (Special Election Period) in which a change can be made at any time during the year.  Click on the link below for access to a grid showing all elections.

Medicare election period cheat sheet

There are 5 companies offering Medicare Advantage Plans (MA or MAPD) in the state of Connecticut.  The 5 companies are Anthem BCBS, Aetna, United HealthCare, Connecticare and Wellcare.  They do not all offer their plans in all counties of Connecticut however.  This post provides an overview of what is available.  Please call or email us for a benefit summary on any of the plans listed below.

WellCare- Offers plans in Fairfield, Hartford and New Haven Counties.  Wellcare has a $0 premium plan that boasts the lowest copays of any $0 premium MAPD in Connecticut.  They also have the only Dual Eligible offering in the state.   Both plans are very strong from a copay and additional benefit standpoint.    Wellcare does have network limitation that need to be considered.  Networks tend to be best in and around cities.  They do not have network in northern Fairfield county.

Anthem BCBS- Anthem offers plans in all counties of Connecticut.  They have an HMO offering for $28 per month.  They also have a PPO (available in limited counties only) for $18.00 that boasts very strong benefits compared to all other PPO plans in Connecticut.   Anthem has a very large network but is missing some major Physician IPA groups in CT.

United HealthCare- United offers plans in all counties of Connecticut.  They have 2 HMO plans ($99 a month plan and $0 a month plan) along with an AARP branded PPO plan for $24.00 a month.   United has an extensive provider network through Connecticut.  The UHC plans do not participate with Quest Labs which should be taken into consideration.  All other major labs do participate however.

Aetna- Currently offer plans in Fairfield, Hartford, Litchfield and New Haven county.  They have a $0 premium plan HMO, $94.00 HMO and a $90 PPO plan.  The $0 premium plan has benefits second only to Wellcare when compared to the other $0 premium plans in the state.  They also have a substantial network to go with the plan and allow for access to any Aetna Medicare HMO provider nation wide.  The Aetna PPO is not competitive at this point due to a $1,000 out of network deductible.

Connecticare- We have a contract with Connecticare but they will not allow to post any comments about their plan.  Call the office if you want information on this company 203-796-5403 or email Edward@Croweandassociates.com

HOW CROWE & ASSOCIATES CAN HELP YOU:

Crowe & Associates is an independent based in Brookfield CT. We are A rated with the BBB and are contracted to sell every Medicare Advantage plan in Connecticut.  We are paid commission from the companies and do not charge clients a fee for our services as a result.  We work with seniors in Connecticut every day to help them find the right Medicare plan to meet their needs.  Feel Free to call our office at 203-796-5403 or email me at Edward@Croweandassociates.com

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