Medicare Advantage Plans (MAPD)

HMO | Medicare Advantage

A Medicare Advantage plan is offered by a private insurance company to Medicare beneficiaries. HMO plans are designed to try and prevent problems before they happen, and they are usually the lowest cost plans. Many have a $0 premium. They are designed to keep patients healthy. This means the plan is designed to be pro-active in catching problems early, and getting the problems fixed quickly before they turn into bigger problems. HMO’s must offer all Medicare Part A (Inpatient Hospital) and Part B (Medical insurance) benefits, and many HMO plans offer Part D (Prescriptions). Many Medicare Advantage plans offer additional benefits that Original Medicare does not offer.

You must live inside the network area, and you must select a primary doctor or internist within the network of the plan you choose as your primary doctor. This primary doctor will manage all of your care, and will refer you to specialists if/when they feel it is necessary. Women may choose a primary care doctor and a female health care provider without a referral. Some HMO plans (like a HMO POS Plan) may allow their members to “self-refer” to other specialists, but that would strictly depend on your plan you choose. If you want to see a particular specialist, you should make sure that the primary doctor you are choosing refers their patients to the specialist you want to see. You may, however, change your primary doctor to another primary doctor within the network if you are not happy for any reason.

HMO plans have “service areas”. Generally speaking, members must use the providers that are contracted within that service area. If you use providers outside of the service area that are not emergencies, urgent care, or dialysis, you will not be covered for that service. If you intend to travel for long periods of time outside of your coverage area or frequently, an HMO plan may not be best suited for you.

All Medicare Advantage HMO plans have a Maximum Out of Pocket. This is the most you’ll have to pay in any calendar year for any medical services. See the details of your plan to find your Out of Pocket Maximum. If this is a concern for you, you may want to investigate Medicare Supplement plans, Like Plan F. CLICK HERE for Supplement Plan F.

Added Benefits. Some HMO plans offer benefits that Original Medicare does not cover like vision and dental, exercise or weight loss programs, hearing aids, over-the-counter items, transportation to your doctor, acupuncture. Look at the details of your individual policy to see what additional items your plan covers that Original Medicare does not cover.

These plans do cover emergencies worldwide.

Disadvantages of an HMO Plan – You are not able to choose to see or go to any doctor or hospital you want. You must use the HMO network of providers and select a primary doctor. If your primary doctor leaves the HMO, you’ll have to choose a new doctor.

Always review your “Evidence of Coverage” and “Summary of Benefits” before making a selection on a plan.

Different types of HMO plans.

HMO POS – These plans may have doctors that you can go see that are out of your normal network for certain services. These costs may be more. Some of these plans require referrals and authorizations, others do not. You’ll need to look in your “Evidence of Coverage” to see how your plan works.

PART B GIVEBACK PLAN – This plan is also referred to as the Part B Premium Reduction Plan. These plans reduce your Medicare Part B premium. You’ll need to see the “Summary of Benefits” to see the details.

MA Plan – A Medicare Advantage plan that does not cover prescriptions.

MAPD Plan – A Medicare Advantage Prescription Drug plan.

Special Needs Plans (SNP) – These plans are available to Medicare Beneficiaries that have special needs. Institutionalized, who are “Dual Eligible” (are on Medicare and Medicaid), and that chronic, severe or disabling medical conditions.