Medicare Advantage

TPMO Disclaimer:

“We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact or 1-800-MEDICARE to get information on all of your options.”

Medicare Plan Eligibility

Medicare is the United States’ Federal Health Insurance Program for people who are 65 or older. It is also available for certain people younger than 65 with disabilities or people with End-Stage Renal Disease. There are several parts to Medicare that contain different coverage.

What is the difference between a Medicare Advantage HMO vs PPO plan?

You might have faced the HMO vs. PPO (Health Maintenance Organization vs. Preferred Provider Organization) decision if your employer offered a choice of these types of group health insurance plans. Now that you’re planning for Medicare, you might have a similar choice if you decide to get coverage through Medicare Advantage. Let’s take a closer look at HMO vs. PPO Medicare Advantage plans available in the Durham, NC area to fully understand the differences. How HMO and PPO plans are alike…

How HMO and PPO plans are alike...

Both Medicare Advantage HMO plans and Medicare Advantage PPO plans are offered through the Medicare Advantage program (Medicare Part C) for Durham, NC area residents. Here are some other “HMO vs. PPO” similarities:

~They’re available through private insurance companies that contract with Medicare.

~Both deliver your Medicare Part A (hospital insurance) and Part B (medical insurance) benefits.

~Hospice benefits are the one exception – those come directly through Medicare Part A instead of through the plan.

~Both typically use provider networks.

~They usually include prescription drug coverage and may have preferred pharmacy networks.

~Like any Medicare Advantage plan, both require you to have Medicare Part A and Part B, and to live within the plan’s service area.

How HMO and PPO plans are different...

Medicare Advantage HMO plans and PPO plans are probably more alike than different. But there are a few “HMO vs. PPO” contrasts:

~Although they generally have provider networks, Medicare Advantage PPOs let you see doctors outside the plan network. You might have to pay higher coinsurance or copayments for seeing out-of-network providers.

~You don’t have to choose a primary care provider with a Medicare PPO, but you do with an HMO.

~If you want to see a specialist, an HMO generally requires you to get a referral. A PPO typically lets you see a specialist without a referral.

Although Medicare Advantage PPO plans may offer more flexibility, your costs (such as the monthly premium) are generally higher under a PPO.

You might need to take a more active role in care coordination in a PPO plan. For example, if you see providers outside the Medicare Advantage PPO plan’s network, you may have to give information about the medical care you have received and your prescription drugs to doctors who treat you.

With any type of Medicare Advantage plan, you’ll need to keep paying your Medicare Part B monthly premium, as well as any premium the plan might charge.

Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether the plan will cover an out-of-network service, you or your provider are encouraged to ask for a pre-service organization determination before you receive the service. Please call the plan’s customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.

The pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

This information is not a complete description of benefits for Medicare Part C coverage. Speak with Durham’s Medicare Advantage experts at ClearBenefits Group LLC or contact the plan for more information. Limitations, copayments, and restrictions that may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

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