The Difference between Medicare HMO and PPO PlansPosted by Medicare Made Clear
Medicare HMO (Health Maintenance Organization) plans and Medicare PPO (Preferred Provider Organization) plans differ mainly in the rules each has about using the plan’s provider network. In general, Medicare PPOs give plan members more leeway to see providers outside the network than Medicare HMOs do.
|Provider Network Rules||Medicare HMO||Medicare PPO|
|Must use network providers for covered services||Yes||No|
|Network primary care provider coordinates care||Yes||No|
|Referral needed for specialist care||Varies by plan||No|
What is a Provider Network?
A provider network is a list of doctors, hospitals and other health care providers under contract with a health plan. Providers in a network agree to accept the plan’s payment terms for covered services, which helps plans manage costs. As a result, plans are able to share the savings with plan members through low out-of-pocket costs.
What is a Medicare HMO Plan?
A Medicare HMO plan is a type of Medicare Advantage plan (Part C). “HMO” is short for Health Maintenance Organization.
Medicare HMO plan members usually have to choose a primary care provider (PCP) from the plan network. The PCP provides general medical care, helps plan members get the services they need and provides referrals to specialists like cardiologists or dermatologists.
While Medicare HMO plans may charge a monthly premium and a deductible, these costs may be quite low – even $0 in some cases. Members usually pay a copayment for covered health care services, after meeting any deductible.
Importantly, a Medicare HMO plan may not cover care received from providers outside the network at all. The plan member could be responsible for the entire cost.
What is a Medicare PPO Plan?
A Medicare PPO plan is another type of Medicare Advantage plan (Part C). “PPO” is short for Preferred Provider Organization.
Every Medicare PPO plan has a provider network. However, these plans also offer coverage for out-of-network care. In addition, PPO plan members may see specialists without a referral.
Medicare PPO plans may charge a monthly premium and a deductible. Members usually pay a copayment for covered health care services, after meeting any deductible.
While Medicare PPO plans may cover out-of-network care, plan members usually pay more than they would for the same service from a network provider.
What Are the Different Types of Medicare Advantage Plans?
There are six types of Medicare Advantage plans. A Medicare Advantage plan (Part C) is another way to get your benefits, rather than through Original Medicare (Parts A & B).
There are six types of Medicare Advantage (Part C) Plans. Watch this video then learn more about Medicare Advantage here: http://bit.ly/2Ec2WUm
Posted by Medicare Made Clear on Tuesday, August 20, 2019
All Medicare Advantage plans combine Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) in a single plan. Most plans offer prescription drug coverage and other benefits not provided by Original Medicare, such as coverage for dental and vision care.
For more information about Medicare, explore MedicareMadeClear.com or 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.Tags: hmo, medicare, medicare advantage, medicare advantage plans, ppo