Question: My sister in law has a $0 premium HMO, and I have a PPO plan which costs a little bit more for the premium. She thinks I am getting ripped off because I have to pay the company money each month and she doesn’t. What do you say?

Answer: I want to say right up front, that the price of the premium is not the only criteria you should measure the value of the plan to buy. You need to evaluate your physicians, your medications, where and how often you seek medical care, are just some of the criteria I would recommend using when choosing your coverage.

Both you and your sister-in-law have Medicare Advantage Plans. Medicare Advantage Plans are plans that replace your Medicare. You do NOT lose Medicare; it just becomes inactive when you enroll in these Medicare Advantage Plans. The Medicare Advantage Plan is responsible to help pay for your health care. I will explain some of the differences between HMO’s and PPO’s.

Medicare Advantage Plans and the companies that offer them are approved by Medicare to provide this coverage. The plans are required to give an amount of coverage equal to Medicare, but often provide additional services. These additional services (not covered by Original Medicare) could be gym memberships, lower cost eye glasses, or health care products provided free of charge. Medicare Advantage plans have a wide variety of premiums in the plans that are offered (in addition to the Part B premium you are already paying). The Medicare Advantage Plans are paid by Medicare to provide you with coverage once you enroll. Medicare Advantage plans require you to pay co-pays for most of the services you receive. These services include doctor visits, Emergency Room visits, Hospitalizations, Physical and Occupational Therapy, and many others. These plans have an out-of-pocket maximum, the maximum amount you will ever have to pay in any given year for your medical care.

Your sister-in-law is enrolled in a type of Medicare Advantage plan called a Health Maintenance Organization (HMO). Her HMO requires her to see her primary care physician for most things and she may need referrals to see specialists or other types of providers. These referrals are usually lifetime referrals. If she chooses to go to a physician, specialist or hospital that is NOT in the network of the company she enroll in, she pays the bill in full. There can be special exceptions to this rule, like worldwide coverage for emergency care or urgent care when she is away from home.

You have a type of Medicare Advantage plan called a Preferred Provider Organization (PPO). Most PPO’s do not require a referral to see physicians and specialists. PPO’s offers both in-network and out-of-network benefits. This means you can pick/choose who you see. The catch is you usually pay more when you see an out of network providers. Sometimes ‘more’ is $5 and sometimes it is significantly more (50% of the bill). There are also different “Maximum Out of Pocket” for in- and out-of-network treatment. Each PPO plan or company develops its own in-network and out-of-network provider list. Sometimes that in-network benefit is mostly local providers where you live. Sometimes that in-network list of providers is a national list of providers, giving you a much bigger selection of where and when to seek treatment.

HMO’s and PPO’s have many similar factors to consider. Before you join any Medicare Advantage Plan, be sure that your doctors participate and if not, be sure you understand how much it will cost to see them.

When enrolling into an HMO, or PPO plan and you need drug coverage, you MUST purchase that drug coverage from the plans they offer. You can’t get that drug coverage from another Medicare Part D plan or company. Most individuals who enroll in an HMO or PPO plan need prescription drug coverage, so they enroll in a plan with that drug coverage built in.

I want to stress again, if you join any kind of Medicare Advantage Plan, you are actually stepping out of Traditional Medicare. You do not lose Medicare; you are simply choosing to use an alternate company to get your Medicare Coverage (opt out). You cannot join a Medicare Advantage plan unless you have both Medicare A & B. When you are in a Medicare Advantage Plan, you don’t use your red, white & blue Medicare card – you only use your Medicare Advantage Plan’s card.

In speaking with multiple individuals about their coverage, choosing a plan is about choosing what is right for you and your individual situation. What works for your sister-in-law, may not work as well for you. So neither of you are wrong if the plan works for you. You probably have different cars, so you can have different health insurance and still be friends.

Janell Sluga is a Geriatric Care Manager helping seniors in our community access services and insurance. To reach her, please email editorial@post-journal.com.