What's the difference between Medicare HMO-POS and PPO plans?

Not much.

They're both types of health plans you can choose for your Medicare coverage. Both types of plans allow you to go to doctors and hospitals outside of your network, but doing so may cost you more. No matter which plan you choose, your doctors will focus on the best care for you. There are, however, a few other things to keep in mind when considering these plans.

What's a Medicare HMO-POS plan?

Health maintenance organizations (HMOs) of today aren't like the HMOs of the past. Some HMOs have a point of service (POS) option as well.

Most HMOs provide care through a network of doctors, hospitals and other medical professionals that you must use to be covered for your care. With an HMO-POS you can go outside of the network for care, but you'll pay more.

  • You'll need to choose a primary care physician (PCP) to coordinate all your care.
  • You typically don't need a referral to see a specialist, but your doctor can sometimes help you get in to see one more quickly.
  • You'll need to work with your doctor to get prior authorization before you get some services. If you don't get prior authorization, some services may not be covered.
  • The HMO and POS portions of the plan have separate deductibles. Care you receive in-network through the HMO has a different deductible than care you receive out-of-network through the POS. The two deductibles cannot be combined - they must be reached separately.

What's a Medicare PPO plan?

A preferred provider organization (PPO) plan gives you a financial incentive to select providers within the PPO network. That's because the health insurer has negotiated contracts with PPO network providers to provide health services at discounted costs. You can go outside of the network for care, but you'll pay more.

  • You don't have to choose a PCP, although selecting one can help you coordinate care and help make sure your health care needs are taken care of.
  • You don't need a referral to see a specialist, but you'll have to make your own appointments with specialists and other health care providers.
  • You don't need prior authorization for services to be covered outside of the network.
  • The amounts you pay toward your in-network deductible and your out-of-network deductible are combined. They don't have to be reached separately.

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