I’m Reviewing Medicare Advantage Plans and They Are Showing HMO and PPO Networks. What Does This Mean?

Medicare Part C is also known as Medicare Advantage. This is a particular type of Medicare coverage that provides individuals an alternative to Medicare Part A and Part A. Medicare Advantage plans are offered via private health insurance companies.

Those who enroll in Medicare Advantage plans still have Medicare. However, those individuals will receive their health care coverage from the Medicare Advantage plan instead of from Medicare Parts A and B (otherwise known as “Original Medicare”).

How Medicare Advantage Plans Work

In addition to covering all of the services that Medicare Part A and Medicare Part B cover, Medicare Advantage plans may also offer additional coverage that isn’t provided through Original Medicare such as hearing, vision, and dental care services.

In order to qualify for enrollment in Medicare Advantage, you must be entitled to Medicare Part A, and also be enrolled in Medicare Part B. You will still be required to pay your Medicare Part B premium – and you will also continue to keep all of your Medicare rights. You will just have additional health care coverage benefits.

Other Coverage Offered Through Medicare Advantage Plans

In many cases, you may also automatically receive Medicare Part D prescription drug coverage if you are enrolled in a Medicare Advantage plan. If this is the case, you should not also enroll in an individual Medicare Plan D prescription drug policy. If this happens, you will be automatically disenrolled from your Medicare Advantage plan and returned to Medicare Parts A and B for your health care coverage, along with your stand alone Medicare Part D plan.

In addition, you should also not enroll in a Medicare Supplement insurance policy if you have Medicare Advantage coverage. This is because the two types of coverage cannot work in conjunction with each other.

Medicare Advantage Plan HMO and PPO Networks

Medicare Advantage plans have different rules for how you may obtain your health care services and procedures. Unlike Original Medicare, which is a fee-for-service program – meaning that you can go to any medical provider or facility that you choose and still be covered – Medicare Advantage plans will typically require that you see providers that belong to certain networks in order to be covered.

This is similar to how HMOs (Health Maintenance Organizations) or PPOs (Preferred Provider Organizations) operate. For example, with a Medicare Advantage HMO plan, you will be able to choose from a network of specific facilities and health care providers for your care.

Here, you will have a primary care physician who will refer you to specialists should you need additional, more specific types of care. Medicare Advantage HMO plans can also include prescription drug coverage that is similar to Medicare Part D.

Because of the in-network restrictions, the premium cost for Medicare Advantage plans are generally lower than for comparable fee-for-service plans. These Medicare Advantage HMO plans also stress different types of wellness programs and preventive care options.

Medicare Advantage also offers a PPO type of option. Like the HMO plans, these plans also offer a network of facilities and providers from which to choose. In this case, however, you may be able to obtain care from out of the network – but the cost will typically be higher, or it may not be covered by your plan at all. The premium cost for a Medicare Advantage PPO is usually slightly higher than that of an HMO plan.

With this in mind, it is important to check on which of your costs will and will not be covered if you are in a Medicare Advantage plan and you are planning to obtain a health care service from an out-of-network provider.

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