Health Maintenance Organization (HMO) plans are one of 5 Medicare Advantage plans. They are perfect for those who want low-cost, network-based coverage at a very low cost.

How an HMO Plan Works

The best way to understand HMO is to break it down into its key features:

  • Network: HMO plans have a provider network. This network is a collection of doctors, hospitals, etc. in a certain area that will accept your Advantage plan. Using in-network providers will ensure you receive coverage and pay less out-of-pocket compared to using out-of-network providers.
  • Primary Care Doctor: Some Advantage plans, including HMO, require you to have a primary care physician. This is a doctor that you are required to visit before receiving other treatments or check ups except in the case of an emergency. Once again, this system helps keep costs very low.
  • Specialist Referral: Along the same lines, HMO plans require a referral before seeing an in-network specialist.
  • Out-of-Network Treatment: The network for an HMO plan is limited, but comes at a significantly lower out-of-pocket and premium cost than other plans. It is very network-focused as a result, so any care received outside of said network will not be covered.

What HMO Covers

This is an introduction to the way in which HMO plans cover a majority of your costs. Here are the main features of HMO:

  • In-network care (except for emergency visits, out-of-area urgent care, or out-of-area dialysis)
  • Required primary care doctor
  • Required specialist referral
  • Prescription drug coverage

As you can see, most HMO plans will also include Part D prescription drug coverage. This is an extremely vital service to Medicare beneficiaries. Most Advantage plans (HMO included) will also cover basic, limited dental, vision, and hearing care. Keep in mind, however, that every plan varies.

How a PPO Plan Works

We understand that these are probably unfamiliar terms. Let’s break down the main features of a PPO plan:

  • Network: You have the option to receive your care from an in-network provider with your plan and pay less, but you also have the option to go outside this network and get care. However, you will pay more in out-of-pocket costs with this option.
  • Primary Care Doctor: A primary care doctor is your in-network person to visit first before anyone else, except in the case of an emergency. If you are required to have a primary care doctor, you will not be able to choose the doctor you visit for a particular need. PPO plans do not require a primary care doctor, meaning you can go straight to the specialist that you believe can help you.
  • Specialist Referral: Some Advantage plans require a specialist referral from your primary care physician before you can receive covered treatment, even if it is in network. With a PPO plan, this isn’t required.


What PPO Covers

You now have more of an idea of what a PPO plan will cover. Here are the main features of a PPO plan’s coverage:

  • Allows for out-of-network visits
  • Does not require a primary care doctor
  • Does not require specialist referrals
  • Covers prescription drugs

As you can see, PPO plans (and almost every other Advantage plan) also include Part D prescription drug coverage. This is a fantastic and necessary benefit for many Medicare recipients. 

Most Advantage plans will also have some form of limited dental, vision, and hearing coverage, and more.

The Cost of a PPO Plan

Like all Medicare Advantage plans, PPO prices will vary depending on the provider and your location. For Medicare recipients, PPO plans are, on average, $30 a month. Some Medicare Advantage premiums may be as low as $0 for certain plans.

To learn more about the cost of a PPO plan in your area, we can help.

We Have Your Back—Call The Coleman Agency

You know what health insurance works best for you, you just need someone to help you get it. The Coleman Agency will work with you to get the coverage you need at a good price. To learn more, give us a call today.

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