What’s the difference between a Medicare Advantage HMO and a PPO?

HMO stands for Health Maintenance Organization and is a type of plan that requires you to see doctors in its network. If you see a doctor outside the network, you will be responsible for all of the costs. The only exception to this is medically necessary emergency or urgent care services. There is also a variation of HMO plans called HMO-POS, which stands for Health Maintenance Organization-Point of Service. These types of plans are similar to HMOs in that you are required to receive most services within the network. However, they have a bit more flexibility and allow you to go out of network for certain services or up to a certain dollar amount. Each plan works differently, so you will need to check to see what is covered out of network for your plan. PPO stands for Preferred Provider Organization and has the most flexibility in allowing you to see doctors out of network. PPO plans have two tiers, an in-network and out-of-network tier. If you see a doctor in-network, you will typically pay less out-of-pocket for those services. If you see a doctor out-of-network, you will typically have higher out-of-pocket costs, but the services are still covered. Call Kevin Leinum Medicare Agent – your local Medicare Expert about what Medicare covers or how enrolling in a Medicare Advantage or Medicare Supplement plan can improve your coverage and reduce your out-of-pocket costs.

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Can a Medicare Advantage plan be “free”?

In some respects, yes. There are Medicare Advantage plans available that have premiums that are $0. However, it is important to know that it does not mean that all of your care is free. You may not have a plan premium to pay, but you will still have to pay your Medicare Part B premium. Additionally, $0 premium plans typically have higher out-of-pocket costs than other Medicare Advantage plans with higher premiums. Additionally, you will likely have few if any supplemental benefits like dental, vision, hearing, transportation, and the variety of other supplemental benefits you see on higher-priced plans. So is a $0 premium Medicare Advantage plan right for you? That depends on many factors, including your health status and financial situation. Talk to your independent Medicare agent, and they can help you make the right choice given your unique situation. Kevin Leinum Medicare Agent – your local Medicare Expert – can help you understand the many parts of Medicare and determine what the right fit is for you. Give us a call to discuss the options available to you.

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How do I know which doctors accept Medicare assignment?

First off, let’s define what Medicare assignment is and the impact it can have on your out-of-pocket costs. One of the most significant potential gaps in Original Medicare is healthcare providers’ ability to bill you for something called excess charges if they don’t accept Medicare Assignment. They may still accept you as a Medicare patient, but they are allowed to bill you for excess charges by not accepting Medicare Assignment. Medicare “Excess Charges” are related to Medicare Part B services. If you are on Medicare and go to a doctor who does not accept Medicare assignment (accept full payment by Medicare), they are allowed to bill you up to 15% above and beyond what Medicare approves for a specific procedure/doctor office visit.

So how do you know if your doctor accepts Medicare assignment? It is simple, ask them or their office staff.

Call Kevin Leinum Medicare Agent – your local Medicare Expert about what Medicare covers or how enrolling in a Medicare Advantage or Medicare Supplement plan can improve your coverage and reduce your out-of-pocket costs.

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What happens if my Medicare doctor is not in the network?

The answer to this question depends on the type of Medicare plan you have. When we talk about Medicare plans with networks, we are generally talking about Medicare Advantage HMO, HMO-POS, or PPO plans. HMO stands for Health Maintenance Organization and is a type of plan that requires you to see doctors in its network. If you see a doctor outside the network, you will be responsible for all of the costs. The only exceptions to this are medically necessary emergency or urgent care services. HMO-POS stands for Health Maintenance Organization-Point of Service. These types of plans are similar to HMOs in that you are required to receive most services within the network. However, they have a bit more flexibility and allow you to go out of network for certain services or up to a certain dollar amount. Each plan works differently, so you will need to check to see what out of network services are covered for your plan. PPO stands for Preferred Provider Organization and has the most flexibility in allowing you to see doctors out of network. PPO plans have two tiers, an in-network and out of network. If you see a doctor in-network, you will typically pay less out-of-pocket for those services. If you see a doctor out-of-network, you will typically have higher out-of-pocket costs, but the services are still covered.

Call Kevin Leinum Medicare Agent to discuss the options available to you.

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What happens if my doctor no longer accepts Medicare payment?

While most doctors accept Medicare, some do not. If you turn 65 and your physician does not accept Medicare, you will have some decisions to make. Choosing to stay with a doctor that does not accept Medicare can result in high out-of-pocket costs for you. There is a difference between a doctor who does not accept Medicare assignment and one who completely opts out of Medicare. If they do not accept Medicare assignment, you may be responsible for an excess charge of up to 15% of a service’s cost. If your doctor opts out of Medicare, you will likely have to pay for 100% of their services out-of-pocket and at commercial rates, which can be significantly higher than Medicare. Unfortunately, if you don’t want to pay those additional out-of-pocket costs, you will have to switch to a doctor that does accept Medicare. If this is the case, talk to your doctor, ask them to recommend a local doctor who does accept Medicare. If your doctor does not accept Medicare, they have probably already prepared for this situation and likely have a Medicare doctor they refer patients to. Kevin Leinum Medicare Agent – your local Medicare Expert – can help you understand the many parts of Medicare and determine what the right fit is for you. Give us a call to discuss the options available to you.

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What are Medicare “star ratings” and how are they measured?

Medicare rates Medicare Advantage and Part D (prescription drug plans) using something called Medicare stars. A 5-star rating is the best, while a 1-star rating is the worst. When you’re trying to choose a Medicare Advantage or Part D (prescription drug) plan, all the choices can be overwhelming. The star rating program was put in place to help you decide which plan is right for you. Medicare Advantage with prescription drug coverage (MA-PD) plans are rated on up to 44 unique quality and performance measures; MA-only plans (without prescription drug coverage) are rated on up to 32 measures, and stand-alone PDP plans are rated on up to 14 measures. The measures used to determine the ratings, including things like the following:

  • How the plan emphasizes staying healthy, including things like screenings, tests, and vaccines
  • How the plan manages chronic conditions
  • The quality of care people with the plan receive
  • Member complaint reports
  • Plan operations, including things like, how they make decisions about appeals, and the results of audits
  • Member experience

You can use the ratings, along with premiums, out-of-pocket costs, and benefits, to choose the right Medicare Advantage plan for you.
Kevin Leinum Medicare Agent – your local Medicare Expert – can help you understand the many parts of Medicare and determine what the right fit is for you. Give us a call at 619.886.5665 to discuss the options available to you.

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What does a Medicare drug formulary with tiers mean?

Every Part D plan has something called a formulary, which is a list of drugs covered under the plan. Each formulary has a set of tiers, and in most cases, Part D plans have between three and six tiers. A lower-tier drug usually has lower copays or coinsurance than a drug in a higher tier.

For example:

Tier 1 – Lowest copay, usually generic drugs
Tier 2 – Medium copay includes some low-cost brand-name drugs
Tier 3 – Higher copay includes brand-name drugs that have generic versions also available
Tier 4 – Higher-co-pay brand-name drugs, and some specialty drugs
Tier 5 – Highest copay includes high-cost specialty prescription drugs

Suppose you are prescribed a drug in a high tier, and a drug that is similar or therapeutically equivalent is also available in a lower-tier at a lower price. In that case, you can ask your insurance company for an exception to get the lower coinsurance or copay.

Call Kevin Leinum Medicare Agent – your local Medicare Expert about what Medicare covers or how enrolling in a Medicare Advantage or Medicare Supplement plan can improve your coverage and reduce your out-of-pocket costs.

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PHONE

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We do not offer every plan available in your area. Currently, we represent 8 organizations which offer 75 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Assistance Program (SHIP) to get information on all of your options. This is a proprietary website and is not associated, endorsed, or authorized by the Social Security Administration, the Department of Health and Human Services or the Center for Medicare and Medicaid Services. This site contains decision-support content and information about Medicare, services related to Medicare and services for people with Medicare. If you would like to find more information about the Medicare program, please visit the Official U.S. Government Site for People with Medicare located at http://www.medicare.gov.

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