UNITED STATES─ Dear Toni: I am turning 65 in July and my husband is retiring January 2021. Both of us are covered by his company health plan.
I am being bombarded by Medicare marketing material regarding different types of Medicare plans that are either HMO or PPO. Friends have told me that a PPO plan is the same as a Medicare Supplement because if your doctor is not in the network, then you can go out of the network. With my husband and I’m visiting doctors in a certain hospital network, it is vital that we keep our doctors. Please explain as I do not want to make a serious mistake in choosing the right type of plan for our Medicare needs. Thanks, Josie from Tampa, Florida.
Josie: You were given WRONG information! Medicare Supplements and Medicare Advantage PPO plans which your friends are referring to are completely different types of Medicare policies.
With a Medicare Supplement, there is NOT a NETWORK of any kind; you have the freedom to use any healthcare provider/facility that accept Medicare assignment or will bill Medicare. The Medicare Supplement will pay for your Medicare out of pocket that Medicare Parts A (In-Patient Hospital) and B(Medical) will not pay for.
With a Medicare Advantage PPO plan, there are lower cost in-network providers or facilities as well as out of network benefits that will cost you more. Many highly marketed Medicare Advantage PPO plans may have $6,700 in-network out of pocket and a maximum of $10,000 for out of network out of pocket.
Many never realize that they may have an out of network provider or facility for their medical claim, but in these current times many healthcare providers/facilities are out of network participants.
Below are some of the differences in the two types of plans:
1) A Medicare Supplement works directly with “Original Medicare.” Medicare pays its share of the Medicare-approved amount for “medically necessary “covered healthcare costs.
2) Your Medicare supplement will pay its share. You chose which doctor, hospital, home health agency, skilled nursing facility, etc. that accepts Medicare assignment for your healthcare. You and your healthcare provider are in control of your healthcare.
3) Medicare Supplement has a monthly premium that may increase each year.
4) Medicare Part D Prescription Drug plan is not included, and you will pay separately for a “Stand alone” Medicare (Part D) Prescription drug plan.
-Medicare Advantage PPO/HMO Plan:
1) To qualify for any Medicare Advantage plan: a) You must be enrolled in both Medicare Parts A & B. b) Live in the service area 6 months out of a year…c) Not have end stage renal disease (kidney dialysis)
2) When you go to the doctor, hospital or visit your pharmacist, you must only use your Medicare Advantage insurance card.
3) A Medicare Advantage Plan must provide all your Part A and Part B benefits and some Medicare Advantage Plans have Part D prescription drug plans included. Also, has “extra” benefits such as gym membership, etc.
4) Healthcare facilities/providers, like MD Anderson accept few Medicare Advantage plans and are generally out of network.
Josie talk to your provider’s office to verify if they accept the Medicare Advantage Plan which you want to enroll in or if that office prefers “Original Medicare with a Medicare Supplement.”
Toni King, author of the Medicare Survival Guide® Advanced edition, which is a simple guide that puts Medicare in people terms, is having a $5 Toni Says® readers discount at www.tonisays.com. If you have any questions regarding this article or any Medicare issues reach out to Toni at 832-519-8664 or email at firstname.lastname@example.org.