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Medicare Managed Care Plans

October 6, 2016

What is a Medicare Managed Care plan?

Medicare Managed Care plans are also known as Medicare Advantage plans, available through the Medicare Part C program. These plans are another way to get your Medicare Part A and Part B coverage (except for hospice care, which Part A covers).Some plans offer additional benefits, like routine vision care and prescription drug coverage.

Types of Medicare Managed Care plans 

Medicare Managed care plans are Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs) that provide basic Medicare coverage plus other coverage to fill the gaps in Medicare coverage.  These types of plans are offered through private insurance companies approved by Medicare; availability and costs among plans may vary depending on where you live.

  • HMO: A Health Maintenance Organization (HMO) plan has a network of doctors, hospitals, and providers that you must use to be covered by the plan. You’re typically not covered if you go out of network for care (except for emergency or urgent care). HMOs require that you choose a primary care physician to coordinate your care; if you need to see a specialist, you must get a referral from your primary care doctor first.
  • PPO: A Preferred Provider Organization (PPO)* plan also has a provider network, and your costs are lower if you use doctors and hospitals in its preferred provider network. However, unlike HMOs, you also have the flexibility to use non-network doctors, although your cost sharing may be higher. You do not need to select a primary care physician or need referrals for specialist care.
  • HMO POS: Some Health Maintenance Organization plans have a Point-of-Service (POS) option. These plans work similarly to traditional HMO plans, which have a network of providers you must use to receive medical care. However, HMO POS plans may also allow you to go out-of-network for certain services, usually at a higher cost sharing.

Medicare Managed Care plans vs. Medicare Supplement plans

Managed Care plans are different from Medicare Supplement (Medigap) plans. If you decide to stay with Original Medicare, another option you may have is to sign up for a Medicare Supplement (Medigap) plan to help pay for Original Medicare’s out-of-pocket costs. Different Medigap plans pay for different amounts of those costs, such as copayments, coinsurance, and deductibles.

 

*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 we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.