Call us now: Toll Free: 866-670-3432 ~ Main Office: 724-603-3403
Question from Mrs. Oliverio:
I now have an HMO Advantage plan with a premium of just over $20/month and it’s going down a couple of dollars next year. It also has what I consider to be a sizeable medical deductible on many services that I almost always meet. There’s a PPO plan with the same company that’s less money and doesn’t have a deductible. Can you explain the difference and how a company can offer a lower priced plan that appears to have better benefits? I’m 86 yrs. old and need some advice before December 7th. I’m afraid to switch. And what does PPO stand for? How is that different from an HMO?
Your situation is why it’s so important to have a good broker who checks to ensure you’re on the best possible plan each year, like we do for our clients. We evaluate the entire Advantage Plan, Supplement, and Part D prescription plan market and then recommend what action should be taken for the upcoming year, which could include staying on the same plan or moving to another plan or company that has a better combination of lower premiums, co-pays, MOOP, and more generous ancillary benefits. Years ago, the HMO you have was the most popular Advantage Plan among our clients. Now, only a handful remain on it because there were better options, a couple with the same company and others that have been introduced since. Had you been a client, we almost certainly would have advised you to move to another plan years ago. I will say your current plan does offer some value for certain people who use oxygen or other durable medical equipment.
How can an Advantage Plan company offer lower priced plans that have better benefits than those that are more expensive? Why don’t they just get rid of the ones that become antiquated or don’t offer as good value as others? I have a few theories and opinions. First, companies almost never discontinue a plan because what that does is force their members to shop which can result in them moving to a competing Advantage Plan carrier. Eliminating a plan also triggers what is known as Guarantee Issue rights and allows those who could never get a Supplement due to current or past medical conditions enroll in one without having those taken into consideration. The last couple times the opportunity was made available, there were many people jumped on that once in a lifetime opportunity to get a Supplement or moved to other Advantage Plan companies.
Believe it or not a couple of the most popular carriers still have plans that have premiums from over $100 to as much as $300 per month that provide no additional value compared to the less expensive plans. In many cases, the more expensive plans even have higher co-pays and much less ancillary benefits like dental and over-the-counter allowances. The real problem in my opinion is there’s no regulation to force these companies to get rid of antiquated and grossly overpriced plans. That needs to happen as it has with Supplements. For example, companies are no longer allowed to offer Supplement plan letters C or F as of January 1st, 2020, because they were a rip off for lack of a better way to put it. So are many, if not all HMO or PPO plans over $50/month as far as I’m concerned. There are hundreds of thousands of seniors overpaying for Medicare Advantage plans in the country.
Mrs. Oliverio said she was afraid to make a change. As I’ve written over and over again, this is common and almost always unfounded. There is absolutely no difference on what is covered from one HMO or PPO to the next regardless of company when it comes to medical services. All are regulated to cover everything as good or better than Original Medicare does. The only differences are premium costs, co-pays for the same services, what the cap is on what you can be billed for medical services annually (known as the Maximum Out of Pocket or MOOP), the amount of ancillary benefits (free stuff) offered, and networks of doctors and hospitals. I know what Mrs. Oliverio is thinking; that moving to another plan could result in tens of thousands of dollars in bills she wouldn’t have on her current plan. Again, that can’t happen. Period. You should absolutely not be fearful of moving to another HMO or PPO plan within the same company or another if you find one that better meets your needs and wants.
PPO stands for Preferred Provider Organization. It means you can leave the plan’s network to get care. You don’t have that option with an HMO. Please be advised that with most companies, a PPO does not mean you can go to any doctor or hospital you want with no strings attached, as many dishonest or poorly trained agents often tell people. There is only one company of the “Big Three,” as I call those who have approximately 90% of the Advantage Plan market in Western PA, that has a PPO with a national network where the vast majority of doctors and hospitals all over the country can be accessed the same way as those in our region along with the same co-pays. Other PPOs have much larger costs for the same services, thousands more, when out of network providers are utilized. Also, with these company’s PPOs, out of network providers can simply refuse to accept the insurance. HMOs on the other hand have zero access to out of network providers with the exception of an emergency.
Lastly, although the December 7th deadline has passed, everyone has another opportunity to move from one Advantage Plan to another, or from an Advantage Plan to a Supplement for a limited time starting in January. If you moved to a plan are concerned you might have made a mistake or thought of moving but got scared like Mrs. Oliverio, feel free to reach out to us to make a no cost appointment to get a second opinion. I estimate that 90% of people we meet for the first time who went elsewhere to enroll in a plan got bad advice.
Make An Appointment
If you would like to make an appointment for a no cost consultation to go over Medicare options, individual ACA marketplace plans, you’re an employer and would like a second opinion on your group policy, or are interested in life insurance, give us a call or email me personally at firstname.lastname@example.org. And keep the great column questions coming! Also, I am now licensed in over 20 states and able to help people choose and enroll in Advantage, Supplement, and Part D plans throughout the country.
Introducing New Facebook Group
Don’t forget to join our new Facebook group, “Ask the Medicare Specialist”, which has the same name as the column, where we post exclusive content and information. Go to our website, getyourbestplan.com, and click on the banner on the homepage to become a member. Thanks for reading everyone!
If you have any questions or concerns regarding this column topic, or would like to make an appointment for a no-cost consultation, please feel free to give us a call – we would be happy to help. I’d like to remind everyone that I do a live call-in talk show called Medicare A to Z every 1st and 3rd Monday of the month on WMBS Uniontown, 590AM and 101.1FM, from 1 to 3 PM. You can listen in on their website, wmbs590.com.
Erie County Area
1105 West 12th Street, Suite – A
Erie, PA 16501
Fayette/Westmoreland County Area
121 North Pittsburgh Street
Connellsville, PA. 15425
21 Yost Blvd., Forest Hills, PA 15221
Mailing Address: 128 Forest Hills Plaza, Pittsburgh, PA 15221
We proudly serve the health insurance and Medicare needs of the following Pennsylvania areas: Connellsville, Uniontown, Greensburg, Mt. Pleasant, Scottdale, Irwin, N. Huntingdon, Murrysville, Monroeville, Plum, Lower Burrell, New Kensington, Pittsburgh, Plum, Oakmont, Penn Hills, Forest Hills, Wilkinsburg, East Liberty, Lawrenceville, Bloomfield, Natrona Heights, Leechburg, Washington, Morgantown WV, Latrobe, Monnessen, Jeanette, Erie, Edinboro, Northeast, Girard, Fairview, Union City, Harborcreek, Corey, Meadville, Waterford, Ligonier, Kittaning, Somerset, Waynesburg, Fayette County, Westmoreland County, Armstrong County, Butler County, Somerset County, Erie County, Crawford County, Venango County, Allegheny Valley, Pennsylvania
We proudly serve the following New Mexico areas: Albuquerque, Rio Rancho, Sante Fe, Bernalillo, Belen, Los Lunas, Espanola, Moriarty, Corales, Tijeras, Cedar Crest, Edgewood, Soccoro, Sandoval County, Sante Fe County, Bernalillo County, Rio Arriba County, Valencia County, Soccoro County, New Mexico Not affiliated with the U. S. government or federal Medicare program.
We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.