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PPO & HMO Plans

PPO and HMO Plans

As an agent, it’s important to have an understanding of the Medicare plans your clients could be enrolling in. That’s why if your client is wanting to opt for a Medicare Advantage plan, you need to be prepared to answer their questions and help them compare plans, such as with two of the most popular Medicare Advantage plans: HMOs and PPOs.

Here is all you need to know about both the HMO and PPO plans.

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Health Maintenance Organizations (HMO) Plans

In HMO plans, members are limited in where they receive their care, but will ultimately pay less out-of-pocket. This is because these plans will have their own provider networks their members can use to get their care from, and will also require that they choose a primary care physician and get referrals when a specialist is needed.

These plans will not provide coverage for out-of-network care, except in situations such as:

• Out-of-area urgent care

• Emergency care

• Out-of-area dialysis

And, because HMOs are a Medicare Advantage plan, they will provide the same coverage as Original Medicare, and possibly include some additional benefits like prescription drug coverage.

As an agent, you will need to have a complete understanding of the benefits that are offered by these plans in your client’s area as each plan and insurance company will vary.

Preferred Provider Organization (PPO) Plans

PPO plans are another popular Medicare Advantage plan. Members of these plans can expect to pay less for working with doctors, hospitals, and other health care providers that are in the plan’s network. However, members aren’t just limited to stay in-network like they are with HMOs. Your client can get out-of-network care with a PPO plan, but just remind them that they will be paying more when getting out-of-network care.

Another thing about PPO plans is that they don’t require their members to choose a primary care physician or get referrals. And, like HMOs, provide the same coverage as Original Medicare with the possibility of having additional benefits.