In this article, you will learn everything you need to know about 2020 Medicare Advantage HMO Plans.
What is a Medicare Advantage HMO Plan?
HMO stands for a health maintenance organization. If you choose an HMO plan, Medicare will pay that insurance company a fee for them to take care of your healthcare services.
These plans have to follow Medicare rules and regulations and they have to offer at least the basic coverage that is offered by Medicare Part A & B.
Most HMO’s offer benefits far beyond what the minimum requirement is from Medicare. The best HMO options on the market offer additional benefits like (+ other):
- Silver Sneakers
- $40 to $100 Monthly Over The Counter (OTC) Allowance
- Transportation Services
- Home Meal Service
- 24 Hr Nurse Line
If you sign up for an HMO Advantage plan you will have to follow rules set by that plan.
You can NOT do whatever you want or go wherever you like as you can with Original Medicare. If you don’t follow these rules you might have to pay all your medical bills out of pocket. That is the trade-off for the additional benefits.
HMO plans require you to use in-network providers and facilities. That means you have to use specific doctors and facilities that a contract with the plan you are interested in. If you don’t use in-network providers or facilities, you will have to pay ALL of your medical bills. An exception to this rule is in emergencies.
Primary Care Doctor (PCP)
When you first sign up for a Medicare Advantage plan, you will have to choose a Primary Care Provider (PCP). This will be your doctor whom you go to on a regular base and they will coordinate all your healthcare.
You can NOT just go to any doctor as you can with Original Medicare. If you don’t like your Primary Care Provider, you have to find another doctor who accepts your plan.
Doctors decide every year which plans they will accept, if your doctor decides not to keep your HMO plan, you will have to find a new doctor.
If your plan decides not to keep your PCP doctor in their network, you will have to find a new doctor as well. You will be informed of any network changes by your plan well ahead of the change and they will tell what options you have.
Sometimes we need to go to a Cardiologist, Dermatologist, Eye doctor or any other doctors who specialize in something you need help with. You can NOT just call them and make an appointment as you can with Original Medicare.
Your Primary Care Doctor has to give you permission (called a referral) to go to that Specialist and he has to provide proof to the HMO plan why that is medically necessary. If you sign up for an HMO plan, get used to the term “Pre-authorization“. That term is used when you need to get permission from an Advantage plan to go see certain doctors or receive certain treatments. That is a basic cost-saving measure to make sure doctors are conscious about the services the suggest to make sure the plan can maintain profitability to be able to offer the extra benefits.
Not all hospitals will be in your plan network. You have to make sure that your Primary Care Provider has admittance privileges at the hospitals you like.
If you have a medical emergency, of course, go to the nearest ER but if it’s not an emergency and you go to a hospital that is not in your network you might have to pay the whole bill.
Most Advantage plans have co-payments when you use services. These co-payments might not apply to you if you have Medicaid or other assistance programs.
To give you an example of the types of co-pays you may find, here are some details of in-network services from a popular Advantage HMO Plan in Florida (34655 zip code):
- Ambulance – $200
- Hospital stay – $100 per day
- Diabetes supplies – up to 20% co-pay
- Diagnostic radiology – up to $125 co-pay
- Outpatient x-rays – up to $100 co-pay
- Therapeutic radiology – 20% co-pay
- Renal dialysis – 20% of the cost
- Chemotherapy – 20% of the cost
All Advantage plans have a Maximum Out-Of-Pocket which protect you from catastrophic medical expenses. Most plans have a $1,500 to $6,000 per year Maximum Out-Of-Pocket limit based on the plan you choose.
When can you join?
If you are Medicare-eligible or you already have Part A & B you can sign up for a Medicare Advantage plan during specific times of the year.
If you are first time eligible for Medicare, you have what’s called your Initial Enrollment Period. During this time you can join any 2020 Medicare Advantage HMO Plans with prescription drug coverage.
If you are already on Medicare and would like to switch plans, you can do so yearly from Oct 15 to Dec 7, this is the annual enrollment period. Here you can switch Advantage plans or join a Part D plan if you want to go back to original medicare.
Jan 1st to March 31 is called the Medicare Advantage Open Enrollment. You can make changes again, this time if you are not happening with the decision you made during the annual enrolment period. Again, you can switch advantage plans or go back to original medicare.
Special Enrollment Period (SEP) can be used throughout the year if you, for example, move or your plan leave the service area. Many reasons fall under the category, and you should always ask if one applies to you.
5 STAR PLANS
Medicare uses a Star Rating System to measure how well Medicare Advantage and Part D plans perform. Medicare scores how well plans perform in several categories, including quality of care and customer service. Ratings range from one to five stars, with five being the highest and one being the lowest.
Plans are rated in each individual category. Medicare also assigns plans one overall star rating to summarize the plan’s performance as a whole. You can use the overall star rating to compare performance among several different plans.
Medicare reviews plan performance yearly and release new star ratings each fall. This means plan ratings may change from year to year.
Medicare Advantage Plans are rated on how well they perform in five different categories:
- Staying healthy: screenings, tests, and vaccines
- Managing chronic (long-term) conditions
- Plan responsiveness and care
- Member complaints, problems getting services, and choosing to leave the plan
- Health plan customer service
Five-Star Special Enrollment Period (SEP)
Generally, you can only change your plan or enroll in a new one during specific times. Special Enrollment Periods are periods of time outside normal enrollment periods, triggered by specific circumstances.
5 Star plans do such a good job that Medicare has included them in the SEP category. This means that you can enroll in a Medicare HMO Advantage Plan in your service area that has an overall plan performance rating of five stars. You may only use this SEP once per calendar year.
IF YOU LIVE IN PASCO, HILLSBOROUGH OR PINELLAS COUNTY, I’m happy to inform you that you have such a plan in our area. If you have Medicare and you don’t like your plan, you don’t have to wait for any enrollment periods. I can help you switch now!