The Rules that Insurance Agents and Brokers Need to Know
What is an HMO, PPO, and all those other Medicare Advantage acronyms that your leads are going to be wondering about. This brief overview of Medicare Advantage (Part C) will help you to remember the most important rules that you need to know.
HMO:
HMO stands for Health Maintenance Organization and has various rules involving networks and referrals. Generally a Medicare Advantage beneficiary on an HMO plan has to choose a primary care physician and get there hospital and doctor services from among the plan’s network. Beneficiaries also have to get referrals if they want to make use of a specialist. Most HMO plans include drug coverage.
PPO:
Preferred Provider Organizations are much like HMO’s in that it involves plan networks. The difference is that with a PPO, the network is “preferred” as opposed to compulsory. Thus, there is no need to choose a primary care physician and no referrals are necessary. However, making use of the services on the plan’s network generally results in lower costs. Most PPO’s also offer drug coverage.
PFFS:
Private Fee for Service plans are unique in that the plan decides on a certain payment structure and service providers may then decide whether or not they want to treat the beneficiary based on that payment plan. A PFFS may have a network and in such a case the beneficiary would have to pay more for the services of a non-network provider. Because of the way the plan is run, there is no need to choose a primary physician or get referrals to see a specialist. Not all PFFS plans offer drug coverage, and beneficiaries may join a PDP if they want drug coverage. It is important to note that service providers have to agree to treat beneficiaries in an emergency.
MSA:
The Medical Savings Account plan has a high deductible health plan and a savings account. A certain amount gets deposited into the beneficiary’s medical savings account every year. Beneficiaries have to pay the deductible amount before their cover begins. Some plans have preferred service providers that will treat beneficiaries at a lower cost, and there is no need for primary care physicians or referrals to see a specialist. MSA beneficiaries have to join a PDP because there is no drug coverage on the plan.
PDP: A PDP is a Medicare approved prescription drug plan.
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