Medicare Advantage HMO Plans

Photo Of Braden Medicare Insurance's Medicare Advantage HMO Plans Poster

WHAT ARE MEDICARE ADVANTAGE HMO PLANS?

ABOUT MEDICARE ADVANTAGE HMO PLANS

Medicare Advantage HMO plans are a popular option in America. According to the Kaiser Family Foundation, approximately 48% of Medicare beneficiaries are enrolled in a Medicare Advantage plan.

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

MEDICARE ADVANTAGE HMO PLANS = MEDICARE HEALTH MAINTENANCE ORGANIZATION PLANS

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 to get care from a network provider. This is called an HMO with a point-of-service (POS) option.

DO ALL HMO PLANS HAVE PRESCRIPTION DRUG COVERAGE?

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

 

DO YOU NEED TO IDENTIFY A PRIMARY CARE PROVIDER (PCP) IF YOU CHOOSE ONE OF THE MEDICARE ADVANTAGE HMO PLANS?

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

 

WILL YOU NEED TO GET A REFERRAL TO SEE A SPECIALIST IF YOU CHOOSE A MEDICARE ADVANTAGE HMO?

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

 

OTHER THINGS YOU NEED TO UNDERSTAND IF YOU ARE CONSIDERING AN HMO PLAN

• 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.

• Follow the plan's rules, such as getting prior approval for certain services when needed. 

MEDICARE ADVANTAGE HMO PLANS

Medicare Health Maintenance Organization (HMO) plans 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. Still, they may do so with different rules, regulations, restrictions, and costs. Some HMOs offer additional benefits, such as vision and hearing care.

ARE MEDICARE ADVANTAGE HMO PLANS AFFORDABLE

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 accepts beneficiaries with ESRD.

• Or, you were enrolled in an HMO before developing ESRD, and you choose to stay in that HMO

  
  

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

WHAT TYPE OF BENEFITS ARE INCLUDED WITH MEDICARE ADVANTAGE HMO PLANS

Once you have joined an HMO, you should receive a benefit card from your plan. 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. 

WILL YOU NEED REFERRALS FROM MY PRIMARY CARE PROVIDER TO SEE A SPECIALIST IF YOU CHOOSE A MEDICARE ADVANTAGE HMO?

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

 

NOW THAT YOU KNOW MORE ABOUT MEDICARE ADVANTAGE HMO PLANS, PLEASE REMEMBER THESE IMPORTANT TIPS BEFORE YOU MAKE ANY DECISION TO JOIN A MEDICARE ADVANTAGE HMO 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 they don't always understand that these benefits aren't

always as 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 than 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% Coinsurance that you have to pay for cancer treatments.  Even if you hit your MOOP, you still have to pay 20%.  Average Rounds of Chemotherapy and Radiation 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 don't have to pay out large sums of money if they don't have to.  It is sad; it is not fair, but it's 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 you need 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 take less money from you when they do not have to accept your plan's rates?  The honest, cold, hard truth is that if they wanted to be a doctor in your plan's network, they would.  The fact that they aren't in your plan's network should tell you everything you need to know.