| Mon, Jul 23, 2012 @ 09:00 AM

HMOs, POSs, PPOs and SNPs – Your One-Stop Shop for Coordinated Care

Posted by Medicare Made Clear

Coordinated Care infoAre you familiar with the above acronyms—HMO, POS, PPO and SNP? If you’d like the convenience of having all your Medicare benefits in one plan plus your care managed by a doctor you trust, you may be interested to know about these types of plans. Learn more below to help you decide if a coordinated care Medicare Advantage plan might be right for you.

Coordinated Care in Medicare Advantage Plans

In some Medicare Advantage plans, your health care is “coordinated.” This means the plan coordinates your health care through a primary care physician. The primary care physician will manage the care you get from specialists and hospitals. With a coordinated care plan, you will generally have to choose doctors and hospitals within the plan’s network. If you go “out of network,” you could end up paying more—or your services might not be covered at all.

Note: Not all Medicare Advantage plans offer coordinated care. Some plans let you get care from any Medicare-eligible provider who accepts the terms, conditions and payment rates of the plan. Examples of this type of plan are Private Fee-For-Service (PFFS) and Medical Savings Account (MSA) plans.

Here are some examples of Medicare Advantage plans that offer coordinated care. These are also called “managed care” plans.

  • Health Maintenance Organization (HMO) plans – An HMO plan requires you to use doctors and hospitals within the plan’s network. You may also have to choose a primary care physician. This doctor would then manage any care you need from specialists. You might need a referral from this doctor before you could see a specialist.

  • Point of Service (POS) plans – A POS plan is a type of HMO plan that lets you visit doctors and hospitals outside their network The group of health care providers, such as hospitals, doctors and pharmacies, that agrees to provide care to the members of a Medicare Advantage coordinated care plan or Medicare Part D prescription drug plan. These providers are called “network providers” and “network pharmacies.”

  • for some covered services. You will usually have to pay a higher copayment or coinsurance, though. Some POS plans don’t require referrals if you want to see a specialist.

  • Preferred Provider Organization (PPO) plans – A PPO-type plan generally gives you more freedom to choose your doctor. These plans also don’t usually require you to have a referral to see a specialist. And you can see doctors outside the The group of health care providers, such as hospitals, doctors and pharmacies, that agrees to provide care to the members of a Medicare Advantage coordinated care plan or Medicare Part D prescription drug plan. These providers are called “network providers” and “network pharmacies.”

  • network The group of health care providers, such as hospitals, doctors and pharmacies, that agrees to provide care to the members of a Medicare Advantage coordinated care plan or Medicare Part D prescription drug plan. These providers are called “network providers” and “network pharmacies.”

  • without having to pay the entire cost yourself. You would typically have to pay a larger share of the cost of your care, however.

  • Special Needs plans (SNP) – An SNP is a special type of coordinated care In Medicare Advantage (Part C), this refers to a kind of health care plan that links providers and services to deliver efficient, cost-effective patient care. Plan members usually have to use doctors and hospitals that are within the plan’s network. These plans are also referred to as “managed care plans.” 

  • plan designed for people with special needs. For example, some SNPs are designed for people with certain illnesses, like diabetes. Others are just for people who live in a long term care facility. Learn more about SNPs below.

Remember, if you need prescription drug coverage, be sure to look at coordinated care plans that provide this benefit. Many do, but some don’t.  

Special Needs Plans – Special Needs, Specialized Care

Some Medicare Advantage plans are designed for people with specific illnesses. This type of plan is called a Special Needs Plan (SNP). They combine hospital care, doctor visits and other outpatient care in a single plan. SNPs may be available for the following groups:

  • People who live in a nursing home or other long-term-care facility because they can’t care for themselves.

  • People who are eligible for both Original Medicare and Medicaid.

  • A program that pays for medical assistance for certain individuals and families with limited incomes and resources. Medicaid is jointly funded by the federal and state governments and managed by the states. Medicaid includes programs that help eligible persons pay Medicare premiums and cost sharing.

    See dual eligible and Medicare Savings Plan.

  • People with certain chronic illnesses, like diabetes or heart disease.

People who qualify for SNPs often need a lot of specialized medical care. That’s why SNPs take coordinated care a step further than other Medicare Advantage plans. The primary care physician still plays an important part of an SNP member’s care. Some SNPs also offer care managers or nurse practitioners to help members get the care they need. Check out the Medicare Made Clear™ website for a helpful example of a care team working together for an SNP member.

The Costs of Coordinated Care

You don’t have to pay extra for coordinated care if you join a Medicare Advantage plan. Your out-of-pocket costs in a Medicare Advantage plan will be different than, say, Original Medicare Parts A & B, though. You might want to weigh these costs against the convenience and other benefits of Medicare Advantage plans. For example:

  • Does the plan charge a monthly premium?

  • You’ll still have to pay your Part B premium, even if you have a Medicare Advantage plan. Will you get any help from the plan with these costs?

    • Does the plan charge deductibles?

    • How much will you pay for each visit or service (copayments or coinsurance)?

    • Which health care services do you need and how often will you need them?

    • What are the rules around using network providers vs. going “out of network”?

    • What is the plan’s yearly limit on your out-of-pocket costs for all medical services?

Next Steps

To find coordinated care Medicare Advantage plans available in your area, check out the Medicare.gov plan finder tool. You can enter as little or as much information as you’d like. Once you do, you’ll get a list of the coordinated care plans available in your area. Then, you can compare them side-by-side to see which plan offers the combination of convenience and coordinated care that might be right for you.

For more information, contact the Medicare helpline 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. If you have questions about Medicare Made Clear call 1-877-619-5582, TTY 711, 8 a.m. – 8 p.m. local time, seven days a week.

Resources:

MedicareMadeClear: Medicare Advantage Plans

MedicareMadeClear: Coordinated Care Medicare Advantage plans

Medicare.gov: Plan finder tool

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