Monday, May 23, 2016

Question: What is a Medicare Advantage HMO?

HMO stands for Health Maintenance Organization. Medicare Advantage HMO plans are the part C of Medicare and are a popular option all over the United States including Texas.  According to the Kaiser Family Foundation, approximately 30% of Medicare beneficiaries are enrolled in some type of Medicare Advantage plan and Medicare Advantage HMOs are common because of the lower premiums and other benefits they often offer.

A Medicare HMO is an organizations through which Medicare beneficiaries can access their Medicare services. This organization handles all of your claims and is compensated by Medicare. The insurance company contracts with certain hospitals, urgent care facilities, durable medical equipment providers, physicians and specialists in your local area to form a network. The medical providers agree to provide your care as instructed by the plan for negotiated rates. In return, one of the benefits to the doctor or hospital is that the plan directs people to them for care by listing the provider in its official network directory.

When you enroll in a Medicare HMO, you agree to obtain your care only through the plan’s network, except in certain circumstances, such as an emergency. Some of the common features of Medicare HMO plan are:

Premiums may be lower or zero as compared to Medigap plans in your area. You must continue to pay your Medicare Part B premium too. Remember, Medicare Advantage HMOs have certain limitations and restrictions by which you must abide.

You must use the organizations local network of healthcare providers and hospitals from which you must seek your care, except in emergencies. Many plans will have you choose a primary care physician and that doctor can coordinate your care by referral to send you to a specialist as needed.

A creditable Medicare Part D drug insurance plan is included in many Medicare Advantage HMO plans. This could save you the cost of purchasing a separate Part D prescription drug insurance plan like when you have a Medicare Supplement.

Unlike a Medicare supplement, in which you pay your monthly premium whether you use it or not,  with Medicare Advantage you pay as you go in the form of co-pays or coinsurance. Each plan has a benefit summary which will tell you how much the provider is allowed to charge for certain services, such as inpatient hospital care, doctor’s visits and lab-work.

Annual Notice of Changes – The benefits formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. You must remember to review the annual notice of change letter/book that the insurance company will send you so that you can decide if you need to make any changes in your coverage.

Medicare Advantage HMO’s usually have a built in safety net by having a yearly out of pocket maximum, which is the maximum amount you would pay for your healthcare for the year. Keep in mind this does not apply to your Part D prescription insurance plan portion.

Reviewing each and every Medicare Advantage HMO insurance plan is a tedious job Get help from a licensed independant insurance agency like Ashford Insurance Services that specializes in Medicare products and can guide you with important information such as a plan’s network size, service area, star rating, and history in the marketplace, and, tell you whether or not your physicians participate in the plan.

Experienced independent agents can also can help you find the right plan  and will consider factors specific to you, such as whether the plan has a built-in Part D drug formulary that includes the medications you need.

I’d love to be your agent so contact me for help today!

Sonia Ashford is an independent insurance agent in the Medicare field, and has delivered hundreds of speeches about turning 65, Medicare Advantage and Medicare supplement insurance to consumers in Tarrant County. A respected agent within the Medicare insurance industry, she is the owner of Ashford Insurance Services. Visit Sonia's agency website to learn more about how she can help you with your Medicare decisions.

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