Medicare Advantage HMO-POS Plans
The different types of Medicare Advantage health insurance plans are designated by acronyms: PPO, HMO, POS, HMO-POS, etc. It’s important to understand the differences between these plans and various plan options.
HMOs (Health Maintenance Organizations) and PPOs (Preferred Provider Organizations) are the most popular Part C plans. You’re probably familiar with these kinds of plans. POS (Point of Services) plans are less well-known. This option is one that can be added to an HMO plan, which gives the HMO plan some benefits of a PPO plan.
A Point of Service plan allows its members to receive care from providers outside of the plan’s network. The member will have less coverage and more out-of-pocket costs if they choose to do this, but at least there is still some coverage. POS plan members must still designate a primary care physician and obtain a referral before seeing a specialist.
Benefits of a Medicare Advantage HMO-POS Plan
Original Medicare provides great benefits for older adults. Plan benefits include coverage for necessary services, but it does not pay for these services completely. That’s where a Medicare Advantage plan can be useful.
The level of benefits included in a Medicare Advantage plan will depend on which specific plan is chosen. The most popular types of Part C plans are HMOs and PPOs. Only about 9% of all Medicare Advantage members choose the HMO-POS Advantage plans, but they are an excellent fit for those who are looking for lower premiums, but still want some flexibility to choose their own providers.
All Medicare Advantage plans provide at least as much coverage as Parts A and B of Original Medicare. Most Part C plans include additional benefits like dental, vision, and hearing services, as well as prescription drug coverage. These are “all-in-one” plans.
An HMO-POS Part C plan replaces the coverage of Original Medicare and gives the beneficiary extra benefits. It does limit the choices the individual has for providers, but does still provide coverage for services rendered by an out-of-network physician.
HMO-POS plans are a great mix of the HMO and PPO plans. They allow for more flexibility than a traditional HMO plan, but generally have lower premiums than a PPO plan. Limitations and restrictions may vary depending on the insurance company providing the plan.
Differences Between HMO-POS and PPO Advantage Plans
An HMO-POS Medicare Advantage plan asks their members to designate a primary care physician. This physician coordinates all of their patient’s care. Since the HMO-POS option allows members to have more flexibility in providers, it’s a better option for individuals who travel often.
For example, let’s say you live in Nevada. You’re planning a long trip to Utah, but you have a few health concerns and you know you’ll need to visit the doctor while on your trip. Prior to leaving, you will work with your primary care physician, who will help you find a doctor in Utah that is also part of your plan’s network. If you only have an HMO plan, this would not be possible as you would only have benefits in Nevada.
Preferred Provider Organization (PPO) plans typically do not require their members to designate a primary care doctor and they can see a specialist without a referral. The opposite is true with HMOs.
With better benefits come higher monthly plan premiums. Medicare Advantage PPO health care plans will have higher monthly premiums than HMO-POS plans.
Medicare Advantage Prescription Drug Coverage
Part D is the stand-alone plan in Medicare that provides prescription drug coverage. They have separate monthly drug premiums and deductibles. However, most Medicare Advantage plans include the drug cost coverage found in Part D plans.
When choosing a Part C HMO-POS plan, individuals should find out if it includes prescription drug coverage. If so, they will need to look at the drug formulary to make sure their prescriptions are included in the policy. The formulary, also known as a Prescription Drug List, is a list of the most commonly prescribed medications and it includes both brand-name and generic prescription medications approved by the U.S. Food and Drug Administration. Prescription Drug Lists often have drug tiers or groups of drugs categorized by cost.
Medicare Advantage plans with Part D coverage are referred to as MAPD plans.
What is a Part C HMO-POS Plan?
A Part C HMO-POS plan is one of the types of Medicare Advantage plans that an individual can purchase to replace their Original Medicare benefits. This plan is a Health Maintenance Organization plan with a Point of Service option (HMO-POS).
This type of plan is a mix of traditional HMO and PPO plans. It offers more flexibility than a traditional HMO and allows the member some coverage during travel. While it does allow for out-of-network benefits, the member will pay more out-of-pocket if they go outside of the plan’s network, similar to how a PPO works.
The HMO-POS Structure
As we’ve mentioned, these plans are a mix between HMO and PPO plans. Traditional HMO plans do not allow their members to receive any benefits if they receive care from an out-of-network provider. If they do, they’ll be paying for the services completely out-of-pocket. The HMO-POS option gives beneficiaries a little more wiggle room.
Since Medicare Advantage plans are sold by private insurance companies, they will all have their own set of rules around these plans. Most of them allow their HMO-POS members to receive health care in other parts of the country if they are traveling.
They still have to choose a primary care physician where they reside, and this physician will help coordinate their care while traveling. This can take away stress from the member by removing the burden of having to find their own provider. Plus, the continuation of care will remain intact while traveling since their main provider will be updated on any care received while traveling.
Traditional HMOs do not have this luxury. If an HMO plan member travels, there will be no coverage outside of their original service area, except for in emergency situations.
Medicare Advantage HMO-POS Eligibility and Enrollment
Any Medicare beneficiary who has already enrolled in Medicare Parts A and B is eligible to apply for a Medicare Advantage HMO-POS plan, with one exception. Individuals who have already been diagnosed with End-Stage Renal Disease (ESRD) are not eligible for any Medicare Advantage plan. Otherwise, an individual can enroll in a Medicare Advantage plan during their Initial Enrollment Period or during the Annual Enrollment Period. Some individuals may even qualify for a Special Enrollment Period.
Medicare Advantage HMO-POS plans are not available in all areas. Work with a licensed agent to find out which plans are available in your area.