What’s a Medicare Advantage HMO and how does it work?
A Health Maintenance Organization (HMO) is a medical insurance plan that uses a network of providers (doctors, hospitals, etc.) to provide medical coverage.
Medicare Advantage combines everything you get in Part A and Part B, usually with added benefits, like prescription coverage, dental, vision, and wellness perks. Usually, an HMO requires you to see your primary care provider (PCP) before you see a specialist. Coverage is limited to a network of providers who contract with the HMO.
In recent years Medicare HMOs have become increasingly popular for three reasons:
- HMOs may be more cost-effective than conventional Medicare
- HMOs have expansive networks which offer many choices of doctors, clinics and hospitals
- HMOs may offer additional benefits like dental and vision coverage plus health and fitness incentives
As an example, in Maricopa County, 32% of Medicare Eligibles are on HMO. Most insurance carriers in the county offer at least one Medicare HMO plan.
A Medicare HMO plan can help optimize costs. Below you can find a guide on how to compare the different plans.
Obviously, choosing your Medicare coverage is an important decision. You should discuss your options with a licensed advisor who can help you make the best choice.
Some things you need to consider:
Which doctors can you see?
Year after year, studies show that people like you are most concerned about which doctors they see. In fact, many people will sacrifice other parts of their coverage to see doctors they are comfortable with and who know their medical history.
Check the list of providers for each plan to see if your doctors are listed. Most doctors contract with multiple insurance plans, so you may be able to find various plans your current doctor accepts.
Remember, like any other business, providers may decide to leave a certain practice, stop accepting a certain insurance plan or retire. Therefore, it is important to choose a network that has your providers and also has a large selection of other providers in your area. Be sure to have our staff help optimize that selection.
Consider choosing doctors and facilities who are preferred cost-share or value-based providers. Insurance companies partner with these to help improve positive outcomes for their members and save money. Your plan may offer lower office visit copays for these providers. Our team is happy to speak with you about the different value-based providers in Arizona.
If all this sounds complicated there’s no need to worry. Connie Health is here for you. Follow our simple registration process to get matched with a local agent who can help find the right plan for your needs.
|Less Desirable Network||More Desirable Network|
|Your Doctors||May be in network & limited choice of other doctors||In network & large choice of other doctors|
|Your Pharmacy||May have preferred pricing||Preferred pricing|
|Urgent Care||Limited availability near you||24/7 urgent care near you|
|Hospitals||Limited choice of hospitals in your area||Large choice of hospitals in your area|
How much will a Medicare Advantage HMO plan cost?
Many carriers offer Medicare Advantage HMO plans with a $0 monthly premium beyond your regular Medicare premium.
Some plans offer low or no copays for visits to primary care doctors and specialists.
When you compare plans, it is important to understand the difference between two key components:
What you pay for medical and/or prescription drugs before your insurance begins to pay for coverage
Maximum Out of Pocket (MOOP):
The maximum amount you will pay out of pocket in a given year
Another key component of your cost is prescription drug coverage, which can vary from plan to plan. Different plans may cover drugs at different rates and tiers. Drug prices can also differ depending on which pharmacy you use to purchase your medications. Our team can help you optimize your prescription drug costs.
Another factor in what you pay for prescription drugs is the Medicare drug coverage gap–commonly referred to as the “donut hole.” Please read our guide on coverage gaps or talk with one of our local advocates to learn the details.
Our team is here to walk you through the different cost tradeoffs based on your personal situation. Optimizing your coverage can lead to significant savings.
Key Differences Between Higher and Lower Cost Plans
|Higher Cost||Lower Cost|
|Monthly Premium||More than $0||Low or no|
|Primary Care Provider||More than $0||Low or no|
|Specialist||More than $30||Less than $20|
|MOOP||More than $5000||Less than $3500|
|Rx (Deductible)||More than $0||$0|
What about other Medicare benefits?
Recently, insurance carriers have included additional health-related benefits in Medicare Advantage policies. It’s easy to understand why. A healthier lifestyle reduces medical costs. The insurance provider and the insured both benefit.
Popular additional benefits included in Medicare Advantage include:
- Over-the-counter items like toothbrushes, vitamins, medical supplies and fitness monitors
- Gym memberships
These benefits can vary widely between different plans and carriers.
Here are some considerations when evaluating a plan:
Dental coverage may include routine preventative services (twice yearly cleaning, exam and x-rays), comprehensive care (minor, restorative and major services) or both. You may be required to visit an in-network dentist.
Vision and hearing coverage is usually for routine services–typically an annual exam. Materials such as hearing aids, glasses and contacts may be partly covered as well.
Coverage of over-the-counter health products like electric toothbrushes, vitamins, medical supplies and fitness monitors is becoming increasingly popular. This is usually a quarterly allowance which may either roll over (if not used) or be “use it or lose it”.
Gym memberships like Silver Sneakers, Silver and Fit, or Renew Active may be offered. Most plans offer this for free. Check if your favorite gym is covered and if extra classes, like water aerobics and cycling classes, are covered.
Remember, these added benefits are a “win-win” for you and your insurance carrier. They save coverage by keeping you healthier. You get coverage and services beyond traditional Medicare and save money on things you may already pay for out of pocket.
Review these additional benefits with our team and choose a Medicare HMO plan with the best combination of benefits for you.
|Limited Benefits||Expansive Benefits|
|Dental||No allowance||$500 or more for preventative|
|Vision||No allowance||$100 or more towards glasses/contacts|
|Hearing||Medicare covered exams cost $20 or more||Medicare covered exams cost $0|
|OTC||$0||$50 or more every quarter|
|Gym||Don't have a gym near you||Has the gym you go to|
Get Your Personal Plan Recommendation
There are many factors you need to consider when you choose a Medicare Advantage HMO plan. We have highlighted some important factors for you to consider above, however we realize each person has their own personal needs. When you meet with our team be open about your healthcare, financial needs and preferences so we can help you find the right solution for you.
Making the right decision might seem challenging given the complexity of Medicare and the choice overload. However, our local team is here to help, at no additional cost to you. It is our job to make sure whatever decision you make is stress-free and you walk away with a full understanding of your selection. Furthermore, we will continue to help you and your family throughout your healthcare journey, serving as a trusted advocate for many years to come.