This blog section contains information on Medicare Advantage plans. Learn about Medicare Part C and discover when you can change your plan during the Open Enrollment Periods. Moreover, find out about Silver Sneakers, Dental Plans, and compare Supplement plans to Medicare Advantage plans.
You can change your Medicare Advantage Plan now – from January 1 to March 31. Otherwise, you will need special circumstances to qualify for a Special Enrollment Period (SEP). If you do not qualify for SEP and it’s past March 31, you will need to wait until the Annual Election Period from October 15 to December 7.
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Why change your Medicare Advantage (MA) plan?
3 Reasons to Change Your Medicare Advantage Plan
Top 3 reasons why seniors change their Medicare Advantage (MA) Plan:
MA Plan Costs
You may be overpaying because your doctors or prescription drugs are out-of-network. Furthermore, your out-of-pocket limits may also be too high. For example, you have a zero or low monthly premium, but your copayments and other out-of-pocket expenses are too much.
You can now change your MA Plan with a higher monthly premium and a lower annual out-of-pocket limit. As a result, you will spend less per year. Your costs are also related to your coverage.
MA Plan Coverage
If you have a Medicare HMO plan and your doctor is out-of-network, your MA plan does not cover these doctor bills. However, Medicare PPO plans do cover doctors out-of-network at higher costs. To avoid the expense of out-of-network doctors, make sure your doctor is in-network.
For better coverage, you may want to change your MA plan now from HMO to PPO. Drug coverage is another reason to change your MA Plan.
MA Drug Plan Coverage
Some MA Plans have no drug coverage, while other MA plans include drug coverage. If your MA Plan does not include drug coverage, you can change your Medicare Advantage plan now.
Furthermore, your MA Plan with drug coverage may not include all your prescriptions. In this case, we recommend you change your MA plan now, so all your prescription medications are covered.
Medicare Part D or Medicare Advantage plan may cover the injectable osteoporosis drug Prolia. When you are in a hospital or skilled nursing facility, Medicare Part A can help pay for Prolia. Furthermore, Medicare Part B may cover a home health nurse visit to inject this drug.
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Medicare Coverage for Osteoporosis Drug Prolia
To enroll in a Medicare Advantage plan, you must have both Medicare Part A and Part B. Furthermore, to have Prolia drug coverage, your Medicare Advantage plan must include drug coverage. However, if you have original Medicare, you can get a standalone Part D drug plan by having Medicare Part A or Part B.
Medicare Eligibility for Osteoporosis Drugs
To be eligible for osteoporosis drugs, you must meet the following conditions:
- Be a woman
- Have a bone fracture that a doctor certifies is related to postmenopausal osteoporosis
To be eligible for Medicare home health services, you must meet the following conditions:
- You have Medicare Part B
- Your doctor certifies you are unable to learn to give yourself the drug by injection
- A family member or caregiver is unable and unwilling to give you the drug by injection
Furthermore, a doctor must certify you are homebound and do not need more than part-time or intermittent skilled nursing care. If you meet the above conditions, Medicare will cover Prolia injections by a home health nurse.
What is Osteoporosis?
According to the Mayo Clinic, osteoporosis “causes your bones to become weak and brittle.” Osteoporosis is most commonly found in white senior women who are past menopause. CDC.gov data shows 24.5 percent of women 65 years old and over have osteoporosis of the femur, neck, or lumbar spine. Thus, 1 in 5 female seniors has osteoporosis.
Symptoms of Osteoporosis
You may have osteoporosis if you have the following signs and symptoms:
- Back pain caused by a fractured vertebra
- Loss of height over time
- A stooped (bent over) posture
- A bone that breaks easier than expected
How to prevent osteoporosis?
The Mayo Clinic says, “good nutrition and regular exercise are essential for keeping your bones healthy throughout your life.” Read the article, Senior Fitness Programs, to learn how you can become more active and improve your strength, balance, and more! To maintain healthy bones, women age 50 and over need 1200 milligrams of calcium (Ca). The following foods are good sources of calcium (per 100 grams):
- Dairy products such as cheddar cheese (707mg)
- Silk soy milk (450mg per cup)
- Canned sardines with bones (382mg)
If you consume less than 1200mg per day, please consider taking a calcium supplement. However, consuming too much calcium is associated with kidney stones. Furthermore, too much supplemental calcium may increase your risk of heart disease. Thus, please limit your calcium intake to 2,000mg per day.
In addition to calcium, you also need Vitamin D for healthy bones. So how much vitamin D do seniors need?
Vitamin D and Osteoporosis Prevention
According to the fact sheet at NIH.gov, Vitamin D helps your body absorb calcium. By consuming recommended amounts of calcium and vitamin D, you can help prevent osteoporosis. Adults 19-70 need 15 micrograms (mcg) or 600 International Units (IU). However, seniors over the age of 70 need 20mcg or 800 IU.
Vitamin D Foods
Very few foods contain vitamin D. However, the US fortifies some food with this vitamin. Please check vitamin D on the product Nutrition Facts label. The following foods are excellent vitamin D sources with a Daily Value (DV) of over 20%.
- Salmon baked (13.7mcg 68% DV)
- Canned tuna (6.70mcg 34% DV)
- Canned sardines with bones (4.8mcg 24% DV)
Furthermore, soy milk and whole milk fortified with vitamin D (3mcg 13% DV) are good sources of vitamin D.
Medicare Costs for Prolia Injections
Your Medicare costs will depend on who administers your Prolia injection and your Medicare plan. If you have Original Medicare and self-administer Prolia inject, your Part D drug plan covers the cost.
However, if you have Original Medicare and a home health nurse administers your Prolia injections, Part B covers 80% of the drug cost. Consequently, you pay the annual Part B deductible, monthly Part B premium, and 20% of the drug price.
Medicare Advantage Prolia Costs
If you have a Medicare Advantage (MA) plan without drug coverage and self-administer Prolia injections, your drug costs are not covered. Consequently, the list price you would pay maybe $1278. To avoid paying such a high price, we recommend you switch to a Medicare Advantage plan with drug coverage. Otherwise, have a home health nurse administer Prolia. Then your cost is only Medicare Part B deductible, the monthly premium, and your MA plan costs.
However, if you have a Medicare Advantage plan with drug coverage, the costs are similar no matter who administers Prolia injections. For example, you can administer Prolia injections yourself or have a home health nurse do it, and your Medicare costs are about the same. You pay Medicare Part B and your Medicare Advantage plan costs.
Are you at Risk for Osteoporosis?
Some medical conditions put you at greater risk for osteoporosis. For example, estrogen deficiency could put you at higher risk for bone loss. Furthermore, if you are diagnosed with primary hyperparathyroidism, your parathyroid gland(s) enlarge, increasing the blood’s calcium levels. As a result, less calcium enters your bones, causing osteoporosis. (Mayo Clinic)
X-rays can show signs of osteoporosis, osteopenia, or vertebral fractures. Also, taking steroid medications can lead to bone loss and cause osteoporosis. For example, long-term use of Prednisone (Glucocorticoids) may result in bone damage. (Osteoporosis.ca)
If you are at risk for osteoporosis, Medicare pays for the costs of bone mass measurements (bone density tests). Every two years, Medicare covers this cost to evaluate your risk of broken bones.
Furthermore, this Medicare-covered test helps your doctor monitor your osteoporosis drug therapy to see if Prolia injections are working. (Medicare.gov)
Does Medicare pay for a Kidney Transplant?
Original Medicare Part A and Part B pay for certain kidney transplant services. Furthermore, Medicare Advantage (Part C) plans also cover certain kidney transplant services. So what exactly is a kidney transplant?
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Kidney Transplant Surgery
Kidney transplant surgery is a medical procedure to remove a healthy kidney from a donor and transplant it into the receiver. The receiver’s non-functioning kidney remains in place, and the surgeon adds the new kidney to the receiver’s abdomen. Kidney donors can live with only one kidney. So what services does Medicare cover?
Medicare Part A Kidney Transplant Services
Medicare Part A covers kidney transplant services for you and your donor. Medicare pays for your inpatient hospital services, the kidney registry fees, blood, and the cost of finding a kidney donor. Furthermore, Part A covers laboratory tests and exams to evaluate your medical condition and potential kidney donors’ condition.
Kidney Donor Coverage
Medicare covers the full cost of care for your kidney donor. Specifically, Medicare covers donor care before, during, and after surgery. Furthermore, should your donor need additional hospital care after surgery, Medicare covers this care as well.
When you enrolled in a Medicare Advantage plan, did you check if a transplant specialist was in your plan’s network?
Medicare Advantage Kidney Transplant Specialist
If your Medicare Advantage plan does not include a kidney transplant specialist, you may be able to change your Medicare Advantage plan. However, if it’s past March 31, you may have to wait until the Annual Election Period starting October 15.
For people with Original Medicare, you have access to all transplant specialists who accept Medicare-assignment. Specifically, Medicare Part B covers doctor services for kidney transplants. What are other medical services covered by Part B?
Medicare Part B Kidney Transplant Service
In addition to doctor services during kidney transplant surgery, Part B may cover care before and after surgery. Furthermore, Part B may cover doctor services for your kidney donor. You may also be eligible for transplant drugs.
Kidney Transplant Drugs
Kidney transplant drugs are immunosuppressants that help prevent rejection of your new kidney. Furthermore, you may need to take these drugs for the rest of your life. If you are not age 65 but were eligible for Medicare because of an End-Stage Renal Disease (ESRD), please do the following:
- Enroll in Part A before your kidney transplant
- Have your kidney transplant surgery at a Medicare-approved facility
According to Medicare.gov, Part B only covers your transplant drugs when you meet the above conditions. Furthermore, ESRD Medicare coverage expires 36 months after the month of your transplant. If you happen to turn 65 during these 36 months, please enroll in Medicare again to avoid losing coverage. Moreover, if you were eligible for Medicare because you were 65 before you got ESRD, your transplant drug coverage has no time limit.
Now that you know the hospital (Part A) and medical (Part B) services covered by Medicare, what do these services cost?
Medicare Kidney Transplant Costs
According to an NPR.org article, the costs of kidney and related care costs about $100,000 per patient. Furthermore, people who lost Medicare coverage after 36 months bear the monthly cost of transplant drugs. If such a person loses their health insurance, these drugs may cost thousands per month!
However, if you have Medicare, Part B pays for your transplant drugs, and you pay the Part B premium. If you take other prescriptions, your Medicare Part D or Medicare Advantage plan may pay these costs. Furthermore, most drug plans charge you a monthly fee. So Medicare Part B pays for your kidney transplant medical costs, do you pay any donor costs?
Kidney Donor Costs
Medicare pays for all your kidney donor costs. Thus, neither you nor the donor pays any deductible, coinsurance, or other costs. However, you pay your share of hospital and medical costs.
Your Kidney Transplant Costs
When you get your kidney transplant surgery in a hospital, you pay the Part A deductible $1484 in 2021. However, you do not pay hospital coinsurance as long as your stay is 60 days or less. Furthermore, you can receive up to 20 days in a skilled nursing facility at no cost.
For Part B medical services, you may pay the Part B deductible $203 in 2021 and 20% coinsurance costs. Medicare may cover the cost of Medicare-approved laboratory tests. If a hospital can not procure blood from a blood bank, you pay for the first three blood units.
If you have a Medicare Advantage plan, what you pay may be different.
Medicare Advantage (MA) plans may cover hearing aids and other benefits not available in Original Medicare. However, Medicare Part B does cover diagnostic hearing test and balance exams. After you pay a $203 Part B deductible in 2021, Medicare covers 80% of your hearing and balance test. (Medicare.gov)
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Before Medicare Advantage covers your hearing aids, you must first have your hearing tested. So who can order your hearing test?
Medicare Hearing Test Coverage
Medicare will only cover your hearing test if ordered by your doctor or other health care provider. Other than your doctor, the following non-physician practitioners can order your hearing test: (asha.org)
- Nurse practitioner
- Clinical nurse specialist
- Physicians’ assistant
Why would a health care provider order a diagnostic hearing test?
Reasons for Diagnostic Hearing Test
Due to a recent illness or injury, you may suffer hearing loss. Please tell a health care provider if you have difficulty hearing. During your healthcare appointment, a practitioner may observe a communication problem and order a hearing test.
For example, the results of your hearing test may demonstrate you can hear just fine. This outcome may lead to another diagnosis, cognitive impairment such as Alzheimer’s disease.
Medicare Advantage with Hearing Aid Coverage
If you have Medicare Advantage (MA) plan that does not include hearing aid coverage, you can switch to a MA Plan that does cover hearing aids. You can switch to a different MA Plan during MA Open Enrollment between January 1 and March 31. After March 31, you may be able to make MA Plan changes by qualifying for a Special Election Period. Otherwise, you will have to wait until Annual Election Period between October 15 and December 7.
Now that you know when you can change or enroll MA Plans, what do hearing aids costs? Furthermore, how much could hearing aid coverage save you?
Hearing Aid Costs
According to Miracle-Ear, “the average cost of a hearing aid is $1,000 to $4,000.” However, the real cost of hearing impairment is miscommunication with people and the environment. For example, not hearing an approaching vehicle could cost your life. Thus, the actual price of not using hearing aids could be injury or death.
When it comes to improving quality of life and preventing accidental death, the value of hearing aids is much higher than the costs. However, with a Medicare Advantage Plan that covers hearing aids, your out-of-pocket costs will be much less. An MA Plan with hearing aid coverage could save you thousands!
Medicare Advantage (MA) plans may include benefits not available in Original Medicare or Medigap Plans. You can get the following exclusive benefits in an MA Plan:
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Find out when you can change your MA Plan to get these benefits.
Changing Your MA Plan
If you want different benefits in your MA Plan, you can switch your plan from January 1 to March 31 during MA Open Enrollment 2021. After this, you can make changes to your Medicare Advantage Plan during the Annual Election Period. However, outside these Open Enrollment Periods, you could qualify for a Special Enrollment Period. Discover the different Medicare Advantage benefits and costs between HMO and PPO Plans.
Medicare Advantage Dental Plans
Medicare Advantage Plans may include routine dental care. For example, your dental plan may cover regular teeth cleanings and dental exams. Read about Dental Plans for Seniors, and discover the importance of regular dental checkups. Furthermore, find out how dental coverage can help you avoid oral cancer and gum disease.
In addition to dental coverage, your MA Plan may also include a fitness program.
Medicare Advantage Fitness Program
People aged 65 or older can enroll in an MA plan that includes the Silver Sneakers’ fitness program. Members of Silver Sneakers have access to over 16,000 fitness locations across the United States. Discover the benefits of joining Silver Sneakers.
However, if you have MA Plan from UnitedHealthcare, you can join their fitness program called Renew Active. This program offers members “thousands of workout videos with Fitbit Premium content.” Furthermore, you get an “online brain health program with exclusive content from AARP Staying Sharp.”
Medicare Advantage Hearing Benefits
Medicare Advantage Plans may provide hearing benefits. For example, Aetna Medicare Plans cover an annual routine hearing exam and hearing aid fitting. Senior Healthcare Direct can help you find a Medicare Advantage plan with hearing benefits. Call 1-855-368-4717 or find your MA Plan.
Read the article Does Medicare cover hearing aids and discover how much an MA Plan could save you.
Medicare Advantage Transportation Benefits
Medicare Advantage Plans may provide transportation to your health care provider. For example, the Aetna Access2Care service gets you there and back. Aetna’s transportation benefit provides non-emergency transport, 24 one-way trips up to 60 miles per trip at no extra cost.
Furthermore, some MA plans may cover trips to your fitness center. Moreover, your Lyft or Uber trips to health care providers may also be covered.
MA Vision Benefits
Original Medicare does cover diabetes eye care or glaucoma. However, MA plans may cover vision benefits, such as the cost of eyeglasses. For example, UnitedHealthcare MA plans offer vision benefits that may include:
- Corrective glasses lenses
- Contact lenses
Call Senior Healthcare Direct at 1-855-368-4717 to shop Medicare Advantage Plans.
Change Your Medicare Advantage Plan
Medicare Advantage Open Enrollment is between January 1 and March 31, 2021. During this period, you can make a one-time change:
- Switch to a different Medicare Advantage Plan with or without drug coverage
- Disenroll from Medicare Advantage and return to Original Medicare and join a Part D drug plan
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Medicare Advantage Plan Changes
During the Medicare Advantage Open Enrollment 2021 Period, you must be in a Medicare Advantage Plan to make a change. If you currently have Original Medicare, you cannot change to a Medicare Advantage Plan during this period. Furthermore, you cannot join a Medicare Part D Plan.
However, if you have a Medicare Advantage Plan, you can return to Original Medicare. Then you will have the option of joining a Medicare Part D Plan. Moreover, you will only have the option of changing your Medicare Advantage Plan until March 31, 2021. (Medicare.gov)
Find the Right Medicare Advantage Plan
The right Medicare Advantage Plan provides you with the following benefits:
- Costs less
- Covers your drugs
- Allows you to go to the providers you want, such as your doctors and pharmacy
- Offers exclusive benefits that Original Medicare does not cover, like dental, fitness program, hearing, transportation, and vision.
Senior Healthcare Direct can help you find the right Medicare Advantage Plan. Click the button below.
What do Medicare Parts cover and cost in 2021?
There are 4 parts of Medicare: Part A, Part B, Part C, and Part D.
- Part A covers inpatient hospital services.
- Part B covers outpatient medical services.
- Part C is Medicare Advantage plan offered by private companies approved by Medicare.
- Part D provides prescription drug coverage to lower the cost you pay for medications.
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Before you receive inpatient hospital benefits, you must first pay Part A deductible of $1484 in 2021. However, you can avoid paying this cost by having a Medicare Supplement plan.
What does Medicare Part A cover and cost in 2021?
According to Medicare.gov, Part A covers the following:
- Inpatient hospital care
- Skilled Nursing Facility care
- Long-term Care Hospitals
Inpatient Hospitals Coverage and Cost in 2021
The first 60 days of inpatient care is covered by Medicare Part A. In other words, you pay $0 coinsurance for each 60 day benefit period. For example, you can be a hospital inpatient multiple times per year and each hospital stay will cost you nothing so long as each stay is 60 days or less. However, hospital stays between 61 days and 90 days will cost you $371 coinsurance per day in 2021.
Skilled Nursing Facility Coverage and Cost in 2021
Medicare Part A also covers 20 days of care in a Skilled Nursing Facility (SNF). Specifically, you pay $0 coinsurance for each 20 day benefit period. Some of the benefits of SNF include physical therapy, meals, and dietary counseling. Therefore, you can get short-term skilled nursing care multiple times per year for no cost so long as each stay is 20 days or less. However, SNF stays between 21 days and 100 days will cost you $185.50 per day in 2021.
Long-term Care Hospital Coverage and Cost in 2021
Medicare Part A covers the first 60 days in a Long-term Care Hospital (LTCH). In particular, the cost of LTCH is $0 for each 60 day benefit period under the following conditions.
- You are transferred to a LTCH directly from an acute care hospital.
- You are admitted to a LTCH within 60 days of being discharged from a hospital.
If the above conditions do not apply, then you must pay Part A $1484 deductible in 2021 before Medicare will pay anything. Furthermore, LTCH stays from 61 days to 90 days will cost you $371 coinsurance per day in 2021.
What does Medicare Part B cover and Cost in 2021?
Medicare Part B covers the following services:
- Medical outpatient services for stays at any hospital or medical facility for less than 24 hours. For example, a stay that occurs overnight but for less than 24 hours is outpatient service.
- Preventive services to prevent illness such as seasonal flu-shot and annual wellness visits.
Medicare Outpatient Coverage and Cost in 2021
Original Medicare covers 80% of medically necessary services and supplies. These Part B medical services include:
- Ambulance Service – transportation to a medical facility.
- Doctor Visits – anytime to see your primary doctor or specialist.
- Mental Health – psychotherapy and counseling to treat conditions such as anxiety and depression.
- Durable Medical Equipment – devices that assist with your medical conditions. For example, blood sugar monitors, oxygen equipment, and wheelchairs.
Before Medicare pays for these medical services and supplies, you must first pay Part B deductible of $203 in 2021. Furthermore, you are responsible to pay the 20% that Medicare does not cover. However, Medicare Supplement Plan C and Plan F pay Part B deductible and your 20% coinsurance.
Medicare Preventive Coverage and Cost
Medicare preventive services cover screening tests that help detect health conditions at early stages when treatment is most effective. In the tables below, we list 31 preventive tests covered by Medicare Part B.
In the above tables, 71% of these screening tests are free after you pay the $203 Part B deductible. Furthermore, 19% of tests require payment of Part B deductible and 20% coinsurance. Finally, 10% of tests you pay absolutely nothing: neither Part B deductible nor 20% coinsurance. If you qualify, you many pay nothing for the following preventive screening tests:
- Nutrition Therapy Service – you pay nothing if you have diabetes or kidney disease.
- “Welcome to Medicare” preventive visit – you pay nothing as long as the doctor does not perform additional tests or services.
- Yearly Wellness Visit – available every 12 months as long as the doctor does not perform additional tests or services.
To receive Part B coverage you need to pay a monthly premium. In 2021, the standard premium for Part B is $148.50.
What does Medicare Part C cover and cost in 2021?
Medicare Part C is an alternative to Original Medicare and covers Part A (Hospital Insurance) and Part B (Medical Insurance). Part C is also known as Medicare Advantage (MA) Plan.
Medicare Advantage (MA) Coverage
MA plans often include Medicare Part D prescription drug coverage. Moreover, many MA plans include extra benefits not covered by Original Medicare. For example, MA plans may include dental, vision, and hearing. Some MA plans even include gym memberships such as Silver Sneakers! MA plans are offered through a network of healthcare providers HMO or PPO.
Medicare Advantage (MA) Costs
To enroll in Medicare Advantage Plan (Part C) you must first be enrolled in Part A and Part B. Most Medicare beneficiaries pay no premium for Part A. However, you will have to pay Part B monthly premiums. In 2021, the standard premium for Part B is $148.50. Furthermore, you will need to pay a monthly Part C premium. According to The Kaiser Family Foundation, the average Medicare Advantage Plan premium is $36 in 2020.
When you add standard Part B and average MA premiums, the total monthly cost is $180.66 in 2020. Conversely, Original Medicare Part B and Part D premiums may only cost on average $177.34 in 2020. However, you may be thrilled to get a gym membership for only a few extra dollars per month!
You can choose a lower premium MA plan. As a result, you may be excited to pay less every month. However, some MA plans will have higher deductibles, copays, and larger out-of-pocket limits. Consequently, the cost to use your health insurance may be much higher. You may be able to avoid these excessive costs by choosing an MA premium of $40 or more.
What does Medicare Part D cover and cost in 2021?
Part D saves you money on prescription drugs. Specifically, it reduces your cost for brand-name and generic drugs. For example, rather than paying the full retail price for medications, you only pay small copayments with Part D. To join a Part D drug plan, you must be enrolled in certain parts of Medicare.
How to Join a Drug Plan
You must have either Part A or Part B to join a stand-alone Part D drug plan with Original Medicare. However, you must have both Part A and Part B to join a Medicare Advantage plan.
Part D Costs for Original Medicare and MA Plans
To enroll in Part D with Original Medicare you need to have either Part A or Part B. However, most people have both Part A and Part B coverage. Since private health insurance companies such as Aetna and Mutual of Omaha provide drug coverage, the price you pay will vary.
Part D drug costs in 2021
All Part D drug plans have a monthly Part D premium. This amount will depend on the income reported on your 2019 tax return. Some Part D plans have an annual deductible which can not be more than $445 in 2021. However, other drug plans may have little or no deductible.
After the out-of-pocket deductible, you pay either a copay or coinsurance for each prescription drug. For example, you pay less for drugs in tier 1 and more for drug in tier 2. Discover the differences in Medicare Part D tier costs. Furthermore, after you and your drug plan spend a certain amount, you enter a coverage gap called the donut hole.
Donut Hole Costs in 2021
In 2021, you enter the donut hole after your plan spends $4,130. Then you pay no more than 25% coinsurance for the plan’s covered brand-name and generic prescription drugs. After total out-of-pocket drug costs are $6,550 in 2021, you exit the donut hole. Learn more about the 4 stages of drug coverage and costs in 2021.
Want More Help with Medicare Parts?
You can speak with a licensed agent at 1-855-368-4717 and get more help with the 4 parts of Medicare: A, B, C, and D. Our team is very experienced at explaining Medicare parts and how they work.
HMO vs PPO: Which Plan is Right for You?
This article compares HMO vs PPO to help you determine which Medicare Advantage Plan is right for you. Differences between Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) include referrals, coverage, cost, and network size.
Differences between HMO and PPO
The chart above shows you the benefit and cost differences between HMO vs PPO. The green values are positive, and the red values are negative. For example, HMO plans have lower deductible and premium costs (green). However, PPO plans have a higher deductible and premium costs (red). The first significant difference between HMO and PPO is referrals.
A PPO (Preferred Provider Organization) plan does not require referrals. However, HMO (Health Maintenance Organization) often require referrals. For example, HMO plans require referrals from your primary care physician (PCP) to see a specialist or have a special test done.
However, Medicare.gov says certain services such as annual mammogram screenings do not require a referral.
A second important difference between PPO and HMO is coverage. With a PPO you can see a doctor outside your network, but it may cost you more. However, an HMO does not provide coverage outside your network.
Thus, you pay all health care costs for out-of-network services with an HMO unless you have an HMO-POS (Point of Service) plan. Moreover, you can get out-of-network HMO coverage for emergency or urgent care.
PPO plans have better coverage and cost more than HMO plans. Some HMO plans may have $0 premium, and HMO-POS plans have a separate deductible. Thus, you pay one deductible for in-network and second deductibles for out-of-network with an HMO-POS plan.
Furthermore, Medicare.gov states an HMO-POS plan will “allow you to get some services out-of-network for a higher copayment or coinsurance.” Senior Healthcare Direct can help you find the most cost-effective HMO and PPO plans. Find plans that include your doctors and medications get your quote.
HMOs have the smallest network of doctors and hospitals. Thus, your choice of medical providers and facilities are more limited with an HMO. On the other hand, PPO plans have larger networks than HMO.
For example, an HMO network may include a county or part of a county, whereas a PPO network may serve a state or multi-state area.