Compare Medicare Advantage Plans
HMO vs PPO. In-network or out-of-network?
What is the best way to compare Medicare Advantage Plans?
The first thing to consider when you start to compare Medicare Advantage plan HMO and Medicare Advantage plan PPO Plans is, how many plans are available to you in your service area (your county). What medical groups are the plan affiliated with? We can help you explore your options. Click “Request Help” or call our office directly to review your county’s plan options, review plan benefits, and discuss lowering your out-of-pocket max.
If you would like to do some preliminary research on your own, you may also visit Medicare.gov to review and compare Medicare Advantage plan HMO & PPO Plans. This government site can be somewhat frustrating when reviewing the plan comparisons without feeling the need to make a profile and/or enter data into Medicare.gov, however, there are ways around the prompts to get directly to the plan finder. Contact us and we will be happy to guide you through the site and explain the Medicare Advantage Plan options presented to you according to your county or “service area.”
Medicare.gov Plan Finder. Enter ZIP code.
We often use the government site– Medicare.gov plan finder tool. This allows us to provide our clients with objective quotes from the government website. This way, our clients know the information on Medicare Advantage Plans being presented to them is not manipulated or “framed” to favor one company’s Medicare Advantage Plan over another. Contact us if you would like some help reviewing your options.
Once the number of Medicare Advantage Plans available to you is established, you can then breakdown which plans suit you best. Remember, these plans are “networked” regardless of their title. For example, the following are the most common networked Medicare Advantage Plan types – HMO– Health Maintenance Organization or PPO- Preferred Provider Organization (usually there is a much higher percentage of HMO Plans). In this example, both plans types (PPO/HMO) are MAPD plans (most are), meaning they all include a Medicare Prescription Drug Plan (Part D). Medicare Advantage (MA) and Medicare Prescription Drug Plan (PD), hence the term MAPD.
To clarify, MAPD plans are technically Part C/Medicare Advantage (all the same thing). Most often always including a Part D Prescription Drug Plan. Refer back to Medicare 101 or the Medicare Plan Map to see how these plans visually work as a “bundled” plan option. Odd? Yes, however, this is how these plans are constructed, so using visual aides is the best way to see how they fit within one of the Medicare plan paths.
What is Medicare Advantage Plan PPO?
A PPO Medicare Advantage Plan will have whats called, “in-network” and “out of network” designations for their plan benefits, copays, co-insurance, OOP (out-of-pocket max). Medicare Advantage Plan PPO are not as common as Medicare Advantage HMO plans. If you are able to have a PPO as a choice, it may work well for you because it does provide you with more access to physicians and providers. Physicians and providers that accept the plan “in-network” will have much lower copays, co-insurance, and out-of-pocket max limits for the plan when used. Physicians and providers that do not accept the plan would be considered “out of network”. Since it is a Medicare Advantage Plan PPO, you have the option of going where you want, however, the access to physicians isn’t always “an advantage” as the costs to do so out-of-network are typically so expensive, you would likely seek physicians and providers “in-network”. Pay close attention to the coverage structure and out-of-pocket max limits with Medicare Advantage PPO plans!
Medicare Advantage Plan PPO
Preferred network vs out-of-network providers. Be sure to review Out-of-Pocket Max (OOPM) copays and coinsurance if your physicians are not preferred providers (in-network).
No networks in an emergency.
For this example, I’ve chosen Placer County (95747- Roseville, CA) to illustrate what a PPO plan looks like– See Plan Comparison Example button below. In the PPO plan below, you have various deductibles, copays, co-insurance, and out-of-pocket max for “in-network” and “out-of-network”. Remember, in this example, you have in-network and out-of-network, meaning the structures of the deductible, copays, co-insurance, and out of pocket max will likely vary drastically. Always review the summary of benefits to get a clear breakdown of the differences for in-network vs. out-of-network providers if you’re considering using the Medicare Advantage PPO with all available Medicare physicians and providers.
If you’re goal is to have the most access and are considering a PPO Plan, you should be considering a Medicare Supplement Plan before enrolling in the PPO.
As this site is intended to be educational and does not market specific Medicare Advantage Plan sales material on the site (you can request any detail, benefit or cost when contacting us directly as we are not able to solicit or sell plan details to you without your permission). For this reason, I will not go into the specific plan benefits, copays and networks of this specific Medicare Advantage Plan. Since this illustration from Medicare.gov shows the premiums, deductibles, and out of pocket max, I’m comfortable reviewing these general topics to give you a better understanding of the plans for educational purposes only. If you review plans on Medicare.gov, you are able to see the breakdown of costs for each plan.
Again, I’m not able to show you the specific details on this site. Please contact us if you would like us to run through the plan’s specifics with you and clarify details of any plan in your ZIP code.
Mentor One Insight
Premium: In this example, there is one PPO Plan. The Aetna “Elite” PPO plan is $0 premium. This means the medical portion of the plan and prescription drug plan do not charge you a monthly premium. Again, remember that this Medicare Advantage Plan PPO is now primary for your Medicare coverage as opposed to keeping Original Medicare, and therefore, will have a specific directory of physicians that take the plan in-network or out-of-network. This is because when you enroll in a Medicare Advantage Plan (HMO or PPO), you are signing over your Medicare to the plan which then becomes primary insurance–not Medicare itself. From a technical standpoint, the out of network coverage is basically saying you have access to Medicare physicians and providers but you’ll likely pay for services at rate of 30-50% more in copays and co-insurance up to the out-of-network OOP Max of $11,300 (for this plan used in the example only). Using in-network physicians and providers will have lower copays, as well as lower OOP Max.
Deductible/co-pays/co-insurance: In this example, the Medicare Advantage PPO plan’s deductible is $750. This deductible refers to the upfront cost you’re responsible to pay before the plan’s coverage kicks in for certain areas of care. For example, let’s say a specialized MRI costs exactly $750 for hypothetical purposes. You would pay $750 for the MRI procedure if it’s the first expense you’ve incurred in the calendar year. The next copay for an additional MRI or another medical service would then fall under the plans co-pay/co-insurance structure once the initial $750 is paid upfront. This deductible is only paid once per year in the 12 month calendar year January 1 – December 31st. For this example, if there was a second MRI or CT scan needed, the co-insurance/copay would likely be between $100-200 depending on the radiological procedure. It may also be more if the procedure is done at an out-of-network facility. Each plan will differ, so do not apply this structure of benefits/copays to every plan. Do your homework or contact us to review the plan benefits to outline the costs of medical appointments and procedures.
Out-of-Pocket Max: In this example, the PPO out-of-pocket max are as follows: $6700 – in-network out of pocket max or $11,300 out-of-network out of pocket max. This means the most you would be liable for medically in a calendar year for Medicare covered expenses. As you can see the PPO “out-of-network” option is much more expensive. These are variable with every Medicare Advantage Plan (HMO or PPO), so be diligent when reviewing Medicare Advantage Plan options for your Medicare coverage.
Part D – Medicare Prescription Drug Plan Included: Another variable you’ll want to consider is how this plans Part D drug plan covers your list of medications. All Part D plans vary as stand-alone plans with Medicare Supplement Plans just as they do for Medicare Advantage Plans HMO/PPO. This is also true of the Part D plan “bundled” inside the MAPD plan. It’s best to list your medications in the Medicare.gov plan finder. Once that is complete, you can then shop the Medicare Advantage Plans with the prescription costs presented with each plan while you review all plans and compare costs, benefits, pricing, etc.
Reminder: If you’re looking for the most access to Medicare physicians and providers you will want to keep Original Medicare and add a Medicare Supplement Plan + Medicare Prescription Drug Plan. It will cost you more monthly, but you will not be subject to the $11,300 out of pocket (comparing to this Medicare Advantage PPO example only). Contact us for more details to compare plans and to breakdown the logic of going with a Medicare Supplement Plan, if you want the most physician/provider access and predictable out-of-pocket costs for the year.
What is a Medicare Advantage Plan HMO?
A Medicare Advantage Plan HMO will have what’s called, “in-network” and “out-of-network” designations for their plan benefits, just like the Medicare Advantage Plan PPO. However, the HMO differs from the PPO in the fact that you are only able to see “in-network” physicians and providers. Out of network is not covered by the plan accept in the case of emergencies and possibly a special exception when the plan cannot fulfill it’s duty to provide the Medicare beneficiary with medical treatment that they are expected to be able to provide according to Medicare. This exception is typically rare and would need to be pre-authorized by your plan before you seek an outside network Medicare physician or provider. Do not count on this being approved, except in very rare circumstances.
The HMO will structure it’s plan with deductibles, copays, co-insurance, and an OOP max (out-of-pocket max). Medicare Advantage Plan HMO will most likely be affiliated with one or more particular medical groups that have accepted the plan’s terms and joined the network for Medicare beneficiaries to seek medical care through. This is one of the ways these plans offer care and benefits at lower premiums. In fact, it’s likely the structure of the managed care HMO system of these plans will incentivize MA Plans to seek lower cost care options as well as require pre-authorizations for many procedures to keep their costs down.
Fee-for-service Original Medicare is not structured this way since it’s not controlled by private insurers offering Part C plans. Hence, why you have more access to physicians and ways to control your out of pocket costs with Original Medicare and a Medicare Supplement Plan.
Most often, the Advantage Plan HMO will require you to designate a primary care physician in the plan’s network, whom you will need to see in order to be directed to specialists and other advanced medical services covered under the plan. Alternatively, Medicare with a Medicare Supplement Plan, will not require you to designate a primary care doctor, not will it require referrals to see specialists like Medicare Advantage or Part C Plans.
Medicare Advantage Plan HMO
In-network & out-of-network providers–be sure to review your plan and confirm Medical group affiliation as well as if your physicians are in-network before enrolling. No networks in an emergency
Using the same example as the Medicare Advantage Plan PPO above, Placer County (95747 -Roseville, CA) to illustrate what an Advantage Plan HMO plan looks like – click on View Plan Comparision Example below. In the Plan Comparison example below, the HMO plan has various deductibles, co-pays, co-insurance, and OOP Max (out-of-pocket max) for “in-network” providers ONLY. Remember, HMO plans do no allow you to seek physicians and providers outside their network accept in emergencies and special circumstances.
As this site is intended to be educational and does not market specific Medicare Advantage Plan HMO & PPO sales material on the site (you can request any detail, benefit or cost when contacting us directly). For this reason, I will not go into the specific plan benefits, copays and networks of the specific HMO plan. Since this illustration from Medicare.gov shows the premiums, deductibles, and out-of-pocket max, I’m comfortable reviewing these general topics to give you a better understanding of the plans for educational purposes only. If you review plans on Medicare.gov, you are able to see the breakdown of costs for each plan.
Again, I’m not able to show you the details on this site. Please contact us if you would like us to run through plans with you and clarify details of any plan in your ZIP code. I will gladly email as much information a I can on any specific plan in your ZIP code and review it with you.
Mentor One Insight
Premium: In this same example there are two Medicare Advantage HMO plans. The premium for AARP “Focus 1” HMO is $19 a month and the Kaiser senior Advantage “B Only North” is $399. Although they break them up into medical and prescription premiums separately (look closely), the end result is the total that you’ll pay monthly since they are “bundled” together. The drug premiums of both plans are $19 and $24 (if technically separated). If you qualify for Extra Help with Prescription Costs program, the program would pay for the monthly drug premiums since they are less than the 2022 avg. Part D Drug Plan price making the respective total plan premiums, $0 for AARP “Focus 1” (- $19 with Extra Help) and $375 for Kaiser Senior Advantage “B Only North” (-$24 with Extra Help). This is fairly technical, so if you have questions, please contact us and we will review this subject for you in more detail as we cannot go into specifics of the plan as Medicare deems this “solicitation” of the plans without consent if we go into each plan benefit for each Medicare Advantage Plan. If you contact us, we can disclose everything to you in detail and review all plans in your ZIP code.
Deductible/Co-pays/Co-insurance: In this example, both Medicare Advantage HMO plan’s deductibles are $0. This makes this portion of the explanation easy, however, the costs for each medical procedure, appointment, etc. will very plan to plan. Review the co-pay, co-insurance, and out-of-pocket max of each plan to find the one that works best for yourself once you find the plan that works with the medical group you would like to see. There can be big differences in the copay, co-insurance, out of pocket max structure of these plans.
Narrowing down the Medicare Advantage Plans by medical group makes this much easier to manage (its not disclosed on Medicare.gov). Once you have the group of plans that your physicians and/or medical group accept in network, then compare premiums and the out-of-pocket max. If you can find a plan that has a lower premium and also a lower OOP Max then that is likely the plan for you (considering they cover your medications well and your preferred doctors take the plan). Why pay more per month and subject yourself to a high OOP Max if you can find a plan with the same physicians and lower your monthly premiums and the potential OOP Max, right?
Out-of-Pocket Max: In this example, the OOP Max are follows: AARP “Focus” 1 HMO – $4900 & Kaiser Senior Advantage “B Only North” HMO – $6700. Both of these OOP Max are in in the middle to upper ends of the spectrum for Medicare Advantage HMO plans, however, they are with highly rated 4-5 star plans and with highly reputable companies. There are OOP Max as low as $999 in this county and as high as $7750 for Advantage HMO plans in Placer County, CA 2022 (Medicare.gov-2022). When it comes to comparing Medicare Advantage Plans, there will be a handful of variables to review if you’re truly searching for the most value. If you would like help reviewing all these variables, we can assist you and breakdown the plans as best we can. It will never be an “apples to apples” comparison like the Medicare Supplement Plans as these Medigap policies are standardized and only differ in cost when comparing the same plan letter at the same age and in the same ZIP code.
Part D – Medicare Prescription Drug Plan Included: Both Advantage Plan HMO plans in this example include a Part D prescription plan inside the Medicare Advantage Plan (Part C). You’ll want to consider how each Medicare Advantage Plan’s Part D Drug Plan covers your list of medications as part of the entire “bundled” package of the Part C product. All Part D plans included with Medicare Advantage Plans vary just as the 20+ stand-alone plans available to add to Medicare Supplements Plans do. The only difference being that you cant customize them to your medical plan as they are again, “bundled”.
To get the most accurate view of the Part D plans included in all the Medicare Advantage Plans in your county, it’s best to list your medications in the plan finder on Medicare.gov. Once that is complete, you can then shop the Medicare Advantage Plans with the prescription costs broken down for each plan, with the ability to compare them side by side with all other variables in one place.
Reminder: If you’re looking for the most access to Medicare physicians and providers you will want to keep Original Medicare and add a Medicare Supplement + Medicare Prescription Drug Plan. It will cost you more monthly, but you will not be subject to the $11,300 out of pocket (this OOP max is only used as an example for this one comparison. OOPMAX vary plan to plan). Contact us for more details to compare plans and to breakdown the logic of going with a Medicare Supplement Plan if you want the most physician/provider access as well as predictable out-of-pocket costs for the year.