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What is a Medicare Advantage HMO?

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Sonia Ashford

Sonia Ashford is the owner of Ashford Insurance, an independent health insurance agency specializing in Texas Medicare insurance.

HMO stands for Health Maintenance Organization.

Medicare Advantage HMO plans are the part C of Medicare and are a popular option all over the United States including Texas.  According to the Kaiser Family Foundation, approximately 30% of Medicare beneficiaries are enrolled in some type of Medicare Advantage plan and Medicare Advantage HMOs are common because of the lower premiums and other benefits they often offer.

A Medicare HMO is an organization through which Medicare beneficiaries can access their Medicare services. This organization handles all of your claims and is compensated by Medicare. The insurance company contracts with certain hospitals, urgent care facilities, durable medical equipment providers, physicians, and specialists in your local area to form a network. The medical providers agree to provide your care as instructed by the plan for negotiated rates. In return, one of the benefits to the doctor or hospital is that the plan directs people to them for care by listing the provider in its official network directory.

When you enroll in a Medicare HMO, you agree to obtain your care only through the plan’s network, except in certain circumstances, such as an emergency. Some of the common features of Medicare HMO plan are:

Premiums may be lower or zero as compared to Medigap plans in your area. You must continue to pay your Medicare Part B premium too. Remember, Medicare Advantage HMOs have certain limitations and restrictions by which you must abide.

You must use the organization’s local network of healthcare providers and hospitals from which you must seek your care, except in emergencies. Many plans will have you choose a primary care physician and that doctor can coordinate your care by referral to send you to a specialist as needed.

A creditable Medicare Part D drug insurance plan is included in many Medicare Advantage HMO plans. This could save you the cost of purchasing a separate Part D prescription drug insurance plan like when you have a Medicare Supplement.

Unlike a Medicare supplement, in which you pay your monthly premium whether you use it or not,  with Medicare Advantage you pay as you go in the form of co-pays or coinsurance. Each plan has a benefits summary which will tell you how much the provider is allowed to charge for certain services, such as inpatient hospital care, doctor’s visits, and lab-work.

Annual Notice of Changes – The benefits formulary, pharmacy network, provider network, premium and/or copayments/co-insurance may change on January 1 of each year. You must remember to review the annual notice of change letter/book that the insurance company will send you so that you can decide if you need to make any changes in your coverage.

Medicare Advantage HMO’s usually have a built-in safety net by having a yearly out of pocket maximum, which is the maximum amount you would pay for your healthcare for the year. Keep in mind this does not apply to your Part D prescription insurance plan portion.

Reviewing each and every Medicare Advantage HMO insurance plan is a tedious job Get help from a licensed independent insurance agency like Ashford Insurance that specializes in Medicare products and can guide you with important information such as a plan’s network size, service area, star rating, and history in the marketplace, and, tell you whether or not your physicians participate in the plan.

Experienced independent agents can also help you find the right plan and will consider factors specific to you, such as whether the plan has a built-in Part D drug formulary that includes the medications you need.

We’d love to be your agent so contact us for help today!


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Picture of Sonia Ashford

Sonia Ashford

Sonia Ashford, “The Medicare Insurance Lady”, has been helping Medicare eligibles in Texas with their Medicare Insurance since 2005.