Most Medicare Advantage plans are structured as HMOs (health maintenance organizations) or PPOs (preferred provider organizations). If you're interested in a Medicare Advantage plan, you'll want to understand the difference between HMOs and PPOs, in both the care they cover and their costs.
AARP/UnitedHealthcare is the most popular Medicare Advantage provider with many enrollees valuing its combination of good ratings, affordable premiums and add-on benefits. For many people, AARP/UnitedHealthcare Medicare Advantage plans fall into the sweet spot for having good benefits at an affordable price.
You have a choice of six types.
A Health Maintenance Organization (HMO) plan is a type of Medicare Advantage Plan that generally provides health care coverage from doctors, other health care providers, or hospitals in the plan's network (except emergency care, out-of-area urgent care, or out-of-area dialysis).
A PPO offers more flexibility with limited coverage or reimbursement for out-of-network providers. An EPO is more restrictive, with less coverage or reimbursement for out-of-network providers. For budget-friendly members, the cost of an EPO is typically lower than a PPO.
Preferred Provider Organization (PPO): PPOs are also a popular choice for seniors, in spite of higher premiums on average. This kind of plan is a bit more flexible than an HMO; PPOs also use a network model, but coverage tends to be broader with some coverage available for out-of-network services.
You continue to pay premiums for your Medicare Part B (medical insurance) benefits when you enroll in a Medicare Advantage plan (Medicare Part C). Medicare decides the Part B premium rate. ... Insurance companies are only allowed to make changes to the premium rate once a year.
The average premium for a Medicare Advantage plan in 2021 was $21.22 per month. For 2022 it will be $19 per month. Although this is the average, some premiums cost $0, and others cost well over $100. For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Medicare Advantage can become expensive if you're sick, due to uncovered copays. Additionally, a plan may offer only a limited network of doctors, which can interfere with a patient's choice. It's not easy to change to another plan; if you decide to switch to Medigap, there often are lifetime penalties.
With Original Medicare, you can go to any doctor or facility that accepts Medicare. Medicare Advantage plans have fixed networks of doctors and hospitals. Your plan will have rules about whether or not you can get care outside your network. But with any plan, you'll pay more for care you get outside your network.
PPO” contrasts: Although they generally have provider networks, Medicare Advantage PPOs let you see doctors outside the plan network. You might have to pay higher coinsurance or copayments for seeing out-of-network providers. You don't have to choose a primary care provider with a Medicare PPO, but you do with an HMO.
Advantages of PPO plans
A PPO plan can be a better choice compared with an HMO if you need flexibility in which health care providers you see. More flexibility to use providers both in-network and out-of-network. You can usually visit specialists without a referral, including out-of-network specialists.
Choosing between an HMO or a PPO health plan doesn't have to be complicated. The main differences between the two are the size of the health care provider network, the flexibility of coverage or payment assistance for doctors in-network vs out-of-network, and the monthly payment.
People with Medicare can get their health coverage through either Original Medicare or a Medicare Advantage Plan (also known as a Medicare private health plan or Part C).
At any point during your first year in a Medicare Advantage plan, you can switch back to Original Medicare without penalty. ... If it isn't your first time in a Medicare Advantage plan, you're not eligible to switch to Original Medicare using a trial right.
Most Medicare Advantage Plans offer coverage for things Original Medicare doesn't cover, like fitness programs (like gym memberships or discounts) and some vision, hearing, and dental services. Plans can also choose to cover even more benefits.
A zero-premium plan is a Medicare Advantage plan that has no monthly premium. In other words, you don't pay anything to the insurance company each month for your coverage. ... (For Medicare Advantage plans with prescription drug coverage, the average premium is $36/month in 2020).
About 7 out of 10 of AARP's Medicare Advantage plans offer $0 premiums. Of AARP plans that have a premium, the monthly consolidated premium (including Part C and Part D) ranges from $9 to $112.
Costs. The additional coverage and flexibility you get from a PPO means that PPO plans will generally cost more than HMO plans. When we think about health plan costs, we usually think about monthly premiums – HMO premiums will typically be lower than PPO premiums.
Medicare Advantage PPOs are types of Medicare Advantage plans that offer provider flexibility for beneficiaries who need it. With Medicare PPOs, you'll receive coverage for any provider you'd like, but you'll pay less if you use in-network providers and more if you use out-of-network providers.
Medicare Advantage plans out of pocket costs: deductibles
A deductible is the amount you must pay before your plan begins to pay. ... Some Medicare Advantage plans have $0 medical deductibles, $0 prescription drug deductibles, and $0 premiums.
Exclusive Provider Organization. Has a network of healthcare providers that it works with exclusively. ... EPOs are usually cheaper than PPOs due to the restrictions on which healthcare providers you can visit. See also Coinsurance vs Copay.