Ask the Medicare Specialist

QUESTION:

Question from Gail: As a traveler, I’m trying to understand the benefit of a PPO vs an HMO. It’s my understanding that an HMO would cover Urgent Care and Emergency Room services even when I’m away from home. ANSWER:

HMO stands for Health Maintenance Organization. A referral from a PCP to see specialists is not necessary with HMOs like it was in the 80’s and 90’s. That was a “gatekeeper” style of health insurance, a horrible model in my opinion, and terribly unpopular. What an HMO means today is insurance companies will only pay claims for services provided by network doctors or facilities. An HMO policy WILL NOT cover any outof-network services with one exception: emergencies. Be advised that services provided at Urgent Care are often coded as physician visits, not an emergency, and a claim is likely to be denied if the Urgent Care facility was not in network, almost certain when out of state. My suggestion for those who have HMOs and are travelling is to go to an Emergency Room for more minor issues like the flu, infections, etc., as well as more serious emergencies like stitches, broken bones, chest pain, etc. According to American Medical Association, the definition of a medical emergency is: “A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that the absence of immediate medical attention could reasonably be expected to result in any of the following: 1. Serious jeopardy to the health of a patient, including a pregnant woman or a fetus. 2. Serious impairment to bodily functions. 3. Serious dysfunction of any bodily organ or part.”

Although I can’t say it could never happen, none of our longest tenured agents, including myself, as well as our client care representatives have ever received a call from a client letting us know an Emergency Room claim went unpaid by their insurance company. We have, however, gotten calls where an out-of-state Urgent Care claim was denied.

PPO stands for Preferred Provider Organization. What it means to those who have them is you may be able to utilize out of network provider. However, to get the lowest cost sharing in terms deductibles, co-pays, and coinsurance, a network provider must be utilized. Far too often I’ve heard from Medicare beneficiaries that they were misled by an agent regarding the freedom to use any doctor or facility without issue. First of all, with employer or individual plans, generally the deductible and Maximum Out of Pocket (MOOP) double for out of network services! Those that would be on a co-pay basis may be subject to the deductible and MOOP. With Advantage Plans, the insurance company only pays between 55% and 70% of what they normally would at an in-network facility and the MOOP increases to $11,300 for out of network services.

It is so important people understand a few things. Out of network providers are not required to accept a PPO with the exception of emergencies. I know for a fact that the Mayo Clinic, one of the top hospitals in the world, does not accept out-of-state PPO’s. The statement that a PPO “allows you to go to any doctor or facility you want,” is false. In addition, most out of network providers are going to want payment in advance if they do choose to accept a PPO. Those who opted to get an outpatient or inpatient surgery performed at an out of network facility almost assuredly would need to come up with that $11,300 prior to services being rendered. Lastly, many PPO plans have the largest allowable in network MOOP of $7,550 as well as higher co-pays. The lowest co-pays and MOOPs are generally found in HMOs.

My advice to those who travel a lot is to make one of two choices: 1) Get a Supplement that doesn’t utilize networks, making any doctor or facility in the country who accepts Medicare Assignment accessible at no additional cost. 2) Go with the one Advantage Plan company in Western Pennsylvania who offers PPO plans that have a nationwide network.

A couple of reminders: I have a live radio show, Medicare A to Z, that airs on WMBS Uniontown 590 am and 101.1 fm every 1st and 3rd Monday of the month from 1:15 to 3. The next show is June 6th. We take calls, answer questions, and get into all things Medicare. The show can also be accessed via the station website, wmbs590.com. Also, all prior columns as well as some webcasts, podcasts, and Facebook Lives can be found on our website. If you have questions for a future column or one of a more personal nature, you can send those to me via email at aaron@getyourbestplan.com.

If you would like to speak with me or another agent, or to set up an appointment for a no cost consultation, give us a call. We can service anyone who lives in Pennsylvania, West Virginia, New Mexico, and Texas. Appointments can take place at any of our office locations, Connellsville, Forest Hills, and Erie. We can also talk over the phone or via the internet, which we call a “virtual meeting.” Those are really neat because they allow clients to see us as well as view the same computer screen the agents are looking at in real time.

Thanks for reading everyone. Have a great Memorial Day!