HMOs and PPOs vs. Medicare Advantage

Coordinated care refers to hospitals, doctors, and other health professionals and providers who work together to provide services to members of the Medicare Advantage policy and communicate closely with the policy to verify that prescription insurance is available. Get quotes and save money at www.medicareadvantageplans2019.org to plan for 2019.

Medicare Advantage HMOs have relatively strong nursing coordination functions. When you enroll in a Medicare Advantage HMO, you generally must select a primary care physician within the network of the policy to coordinate your care. The PCP will provide your routine medical care and coordinate any special care you may need, directing it to specialists who join the network. Organize admission to participating hospitals, rehabilitation centers or qualified care centers; and the use of pharmacies, outpatient laboratories and participating medical providers, as necessary.

Medicare Advantage PPOs also provide nurse coordination, but provide more flexibility in choosing health care providers. When you join a Medicare Advantage PPO policy, you generally do not need to select a PCP to coordinate your medical care. Normally, you do not have to go through a PCP to receive insurance benefits when you visit a specialist. Generally, you can see each health care provider. However, your insurance is usually higher and your medical expenses are lower if you see providers who participate in the policy’s network.

Unlike a Medicare Advantage HMO policy, you may have to play a more active role in coordinating care in a PPO policy. For instance, if you notice plan providers outside the network of Medicare Advantage PPO, you may need to call the policy to verify that the pre-authorization for inpatient treatment has been made in accordance with policy rules. You may need to provide the treating doctor with information about your medical care and prescription drugs.

Performance and cost sharing insurance: In a Medicare Advantage HMO policy, you generally need to get your medical care and services from doctors, hospitals, and other health care providers who participate in the policy’s network to get insured benefits. There are some exceptions when the Medicare Advantage HMO policy provides insurance for non-participating providers:

  • Emergency care
  • Out-of-range dialysis treatment when traveling outside of the policy’s service area
  • Urgent care out of the area when traveling outside of the policy’s service area
  • Out-of-network services previously approved by the Medicare Advantage HMO policy

If you are participating in a limited Medicare Advantage HMO policy and you visit health care providers outside of the policy network, you will generally have to pay the full cost of the care or service you receive.

On the other hand, Medicare Advantage PPO policies generally have insurance within the network and an out-of-network level of performance. You can switch between the two levels of benefit insurance if you select care providers during the benefit year. When you join a Medicare Advantage PPO policy, you generally receive insured benefits when you use hospitals, doctors or other health professionals, and providers outside the network of the Medicare Advantage PPO. However, you generally pay a greater part of the cost of the care or services you receive from them. https://www.ssa.gov/