Medicare Advantage Plans in Missouri: HMO vs. PPO

medicare advntage hmo vs.ppo

If you are turning 65 and are new to the world of Medicare choosing the best coverage option is not that easy. Medicare Advantage plans often can be tricky and misunderstood, but don’t worry because in this blog we’ll discuss the best Medicare Advantage plans and their main differences. 

What is Medicare Advantage?

Medicare Advantage Plans are also commonly known as Medicare Part C and are a substitute way to receive your primary coverage. They are not Original Medicare but rather they are managed care plans offered by private insurance companies, just like Missouri Insurance Advisors. However, private insurance companies need to be previously approved by Medicare before selling Medicare Advantage Plans.  They include Parts A and B such as Part D (prescription drug coverage all into one).

But, to get Medicare Advantage you need to be enrolled in both Parts A and B and pay for Part B’s monthly premium which is 170.10$ for most people in 2022. With the MA plan, you no longer use your red, white, and blue traditional Medicare card anymore because Medicare Advantage Plans replace your traditional Medicare benefits. 

They must follow certain rules that are set by Medicare, but they can establish their own sets of copays and coinsurance for covered services. This means that you can be responsible for copays and coinsurance for some covered healthcare services.

Medicare Advantage Plans also have the maximum out-of-pocket costs in each calendar year, and after you reach this amount your coverage needs to pay for the rest. In 2022, maximum out-of-pocket limit costs can reach up to 7550$. 

HMO vs. PPO in Missouri

There are four main types of Medicare Advantage plans HMO, PPO, PFFS, and SPN. The most popular ones are HMO (High Maintenance Organization) and PPO ( Preferred Providers Organization) so in this blog, we will be comparing the differences between those two plans.

HMO and PPO offer similar types of coverage, but there are some main differences between those plans that you need to consider before enrolling in one or another. 

With an HMO plan, you are required to use in-network doctors and hospitals. In other words, as a Medicare Advantage policyholder, you will get no coverage if you go to out-of-network doctors, except for medical emergencies.

You’ll also need to establish a primary care physician and the PCP needs to give you a referral to see specialists. This means that all of your healthcare services will be coordinated between you and your primary care physician. For example, if you have heart trouble you will first book an appointment with your PCP. Then your doctor will provide you with a referral to see an in-network cardiologist.

With a PPO plan, you don’t need to establish a primary care physician or a referral to see specialists. Those plans give beneficiaries more flexibility because they provide the option to go to the doctors and hospitals in and out of PPO’s network. However, you will need to pay more for out-of-network services. So, you will save your money if you choose a doctor or specialist, or hospital which is in your network.

HMO vs. PPO Costs

HMO plans have lower out-of-pocket costs than PPO Plans. As a Medicare Advantage policyholder if you go to see a doctor you will usually have lower copays, lower out-of-pocket costs if you need to go to the hospital as much as a lower cost-share in general in comparison to a PPO Medicare Advantage Plan.

As previously explained, those plans are more restrictive so you’ll still need to stay within an HMO’s network of doctors and hospitals to avoid expensive costs (except for emergencies).

With PPO plans you will usually pay higher out-of-pocket costs if you go outside your plan network but you have that option, which provides you with more flexibility than with the HMO plan.

On the other hand, with the PPO plan, you will usually have higher copays, and your hospital bill is generally higher in comparison to the HMO plans.

How do I choose between HMO or PPO?

Generally, if you are somebody who likes to go to a bunch of different doctors and don’t want to choose a primary care physician you need to go to every time, then the PPO plan might be the right option for you. However, you still need to consider higher out-of-pocket costs, but if you are not restrictive to your budget and are willing to pay a little bit more for flexibility then you will not be mistaken to choose a PPO plan.

Besides, if you don’t like or usually don’t go to a large number of different doctors and you don’t mind having a PCP who will coordinate your every medical need, an HMO plan is then a better option for you. Even though HMO plans are more restrictive than PPO plans they still have lower out-of-pocket costs that can help you to save more money. 

Still, Medicare Advantage Plans can be very complex, so we are advising you to talk with the licensed Medicare agent here in Missouri Insurance Advisors. We have a lot of experience in the world of Medicare and can help you choose the best plan according to your budget and needs.

You don’t have to do this alone, call us ((417) 323-2431)or text us today, we are here to help!

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