Question from Rick: Do I need a PPO Advantage Plan to avoid needing referrals for specialists? I have a friend who says I do.

Answer: In Pennsylvania, you don’t need referrals to see specialists with HMO Advantage Plans. So, at this time, you do not need a PPO.

However, in some states, including Florida, people who have HMO Advantage Plans do indeed need a referral from their PCP to see specialists. And that requirement has caused havoc for doctors and their patients. In fact, many doctors are no longer taking patients with HMOs because it’s become too time consuming and expensive. Doctors literally have had to hire full-time employees just to deal with those requests. 

I had a client in Saint Augustine Florida who wanted to choose an HMO Advantage Plan that offered really good value, but we couldn't find a single primary care doctor who was in network with the plan. Because he couldn’t pass medical underwriting to get a Supplement, the only options where he could find a PCP that would accept an Advantage Plan were PPOs that had huge six-day hospital co-pays, between $2,100 and $2,800, as well as more expensive co-pays for blood work, X-Rays, MRI’s, and CT scans. The PPOs also had Maximum Out of Pocket (MOOP) limits almost $3,000 higher than the available HMOs.

I certainly hope we don’t get to that point in Pennsylvania with HMOs, but it’s possible. The last couple months I’ve been writing about my prediction of networks becoming smaller as well as doctor and hospital choices fewer for those who want or need lower Advantage Plan premiums and co-pays. And if referrals for specialists are required in the future, that means more hoops to jump through to get care. 

Supplements don’t have networks or require referrals to see specialists in any state. Those on Supplements also don’t need to get prior authorizations for other medical services such as MRIs, CT scans, or outpatient surgeries that are necessary for those on either HMO and PPO Advantage Plans. 

Unfortunately, so many current Medicare beneficiaries, when first going on Part B, were not told about some of the risks of Advantage Plans including the possibility of not being able to enroll in a Supplement in the future. They were lured in by zero or low premiums and the promise of free stuff that is now starting to be reduced or eliminated. Many agents fail to even mention Supplements as an option because they wanted the much higher commissions Advantage Plans pay. 

As I’ve often stated, Advantage Plans are a vital part of Medicare and necessary as an option to Supplements. But before choosing an HMO or PPO, it’s imperative that both the risks versus rewards, pros and cons are explained and compared to Supplements. 

I highly encourage those on Advantage Plans who are currently healthy enough to pass underwriting to move to a Supplement to give it serious consideration while they can. 2026 still offers good value in Advantage Plans, but in 2027 or beyond, if Pennsylvania plans end up resembling those in other states and HMOs begin to require referrals for specialists, many of those who decided to wait to get a Supplement may end up regretting it. For quote or to pre-screen for underwriting on Supplements, or if you have any other Medicare related questions or concerns during the Medicare Annual Enrollment Period that runs through December 7^th, give our office a call or email me personally, Aaron@GetYourBestPlan.com.