Medicare Blog

3. what is the relationship between hmo managed senior care products and medicare?

by Marcus Pfeffer Published 2 years ago Updated 2 years ago

Medicare is a national health insurance program for seniors or those with disabilities. Medicare Advantage is Medicare's managed care program. If you join Medicare Advantage, you get all your care through an HMO or PPO that has a contract with Medicare.

Full Answer

What is managed care and HMOs?

Managed Care and HMOs “Managed care” refers to that type of health care system under which medical care and treatment is managed by the entity paying the bills, and not the medical care or treatment provider (physician, hospital, etc.).

What is the difference between Original Medicare and managed care?

Most managed care plans provide additional benefits for services that Original Medicare doesn’t include. Benefits can include routine vision, dental and hearing services. Additionally, managed care plans offer prescription drug coverage.

What is the difference between managed care and PPO?

Managed Care vs PPO Like the HMOs, with some differences. PPOs provide more choices for choosing a doctor or health-care facility. Even though PPO insurance has a network of providers, the restrictions are less than HMOs.

What are the pros and cons of Medicare managed care plans?

With the good, comes the bad, in life as well as Medicare coverage. Let’s look at the pros. Medicare Managed Care plans include equivalent coverage as Parts A and B. Plus, these plans include extra benefits like routine vision, hearing, and dental services.

What is the relationship between Medicare and HMOs?

Like all Medicare Advantage Plans, HMOs must provide you with the same benefits, rights, and protections as Original Medicare, but they may do so with different rules, restrictions, and costs. Some HMOs offer additional benefits, such as vision and hearing care. You must have both Parts A and B to join a Medicare HMO.

What is the difference between Medicare and Medicare HMO?

A Medicare Advantage HMO plan delivers all your Medicare Part A and Part B benefits, except hospice care – but that's still covered for you directly under Part A, instead of through the plan. Medicare Advantage plans are offered by private, Medicare-approved insurance companies.

Which of the following statements is correct concerning the relationship between Medicare and HMO?

Which of the following statements is CORRECT concerning the relationship between Medicare and HMOS? HMOS may pay for services not covered by Medicare.

What does HMO mean in Medicare?

Health Maintenance OrganizationHealth Maintenance Organization (HMO) Medicare.

What are the advantages of an HMO or PPO for a Medicare recipient?

It's important to consider and compare the differences between Medicare Advantage HMO and PPO plans. HMO plans typically have lower premiums and less out-of-pocket costs. PPO plans have higher premiums and cost sharing, but greater flexibility to choose your doctor or other health care provider.

What is the difference between health maintenance organizations and preferred provider organizations?

To start, HMO stands for Health Maintenance Organization, and the coverage restricts patients to a particular group of physicians called a network. PPO is short for Preferred Provider Organization and allows patients to choose any physician they wish, either inside or outside of their network.

What are the differences between Medicare and Medicaid?

The difference between Medicaid and Medicare is that Medicaid is managed by states and is based on income. Medicare is managed by the federal government and is mainly based on age. But there are special circumstances, like certain disabilities, that may allow younger people to get Medicare.

Which type of care is not covered by Medicare?

does not cover: Routine dental exams, most dental care or dentures. Routine eye exams, eyeglasses or contacts. Hearing aids or related exams or services.

How is emergency care covered for a member of an HMO?

If you need emergency or urgent care and are outside your plan's service area, your plan must cover the care even if it is provided by an out-of-network doctor. Some HMOs offer a point-of-service (POS) option, which allows you to see out-of-network providers for certain services without referral or prior authorization.

What is the goal of the HMO?

HMOs are a type of managed care designed to maintain the health of their patients cost-effectively. A primary method HMOs use to achieve these goals is to coordinate health services and care provided to patients.

What are the advantages of HMO?

Advantages of HMO plansLower monthly premiums and generally lower out-of-pocket costs.Generally lower out-of-pocket costs for prescriptions.Claims won't have to be filed as often since medical care you receive is typically in-network.More items...•

What are the two important components of an HMO?

HMOs have their own network of doctors, hospitals and other healthcare providers who have agreed to accept payment at a certain level for any services they provide. This allows the HMO to keep costs in check for its members. There are 2 features that set HMOs apart from other types of healthcare plans: cost and choice.

Why do doctors not like Medicare Advantage plans?

If they don't say under budget, they end up losing money. Meaning, you may not receive the full extent of care. Thus, many doctors will likely tell you they do not like Medicare Advantage plans because private insurance companies make it difficult for them to get paid for their services.

Is Original Medicare an HMO or PPO?

There are several differences in costs and coverage among Original Medicare, Preferred Provider Organizations (PPOs), and Health Maintenance Organizations (HMOs). The table below compares these three types of Medicare plans.

Which is better PPO or HMO?

HMO plans typically have lower monthly premiums. You can also expect to pay less out of pocket. PPOs tend to have higher monthly premiums in exchange for the flexibility to use providers both in and out of network without a referral. Out-of-pocket medical costs can also run higher with a PPO plan.

What is the maximum out of pocket for Medicare Advantage plans?

The US government sets the standard Medicare Advantage maximum out-of-pocket limit every year. In 2019, this amount is $6,700, which is a common MOOP limit. However, you should note that some insurance companies use lower MOOP limits, while some plans may have higher limits.


As the Medicare program enters its fourth decade, it is increasingly likely that major changes will be made in how it functions. The debates are beginning concerning its long-term restructuring to deal with the impending pressures of baby boomers in the second and third decade of the twenty-first century.


The term health maintenance organization has a generally accepted definition in the research literature and in legislation with respect to the various federal and state programs that regulate HMOs.


Nationally, roughly 53.5 million people are enrolled in HMOs (about 44 million in “pure” HMOs and approximately 9.5 million in point-of-service plans).


The distribution of medical care expenditures is highly skewed, with a small fraction of the population having very high costs and the vast majority using few or no services in a year. This is true for both Medicare and other populations. Typically, about 10% of the eligible group accounts for 75% of expenditures (See Figure 18 in Reference 21 ).


A recent review summarizes the published literature on HMO performance from 1986 through 1996 ( 13 ). This section highlights those findings that are most relevant to an understanding of Medicare and HMOs.


There are a wide range of policy issues concerning the role of managed care plans in the Medicare program. However, we focus on two major issues: assuring quality of care and setting appropriate payment levels for health plans.


This chapter is intended to set the stage for further thinking about the role of managed care in the Medicare program, recognizing that this is a rapidly changing area. New policy proposals are under development while this is being written, and some may have been passed by the time this is read.

What is managed care?

“Managed care” refers to that type of health care system under which medical care and treatment is managed by the entity paying the bills, and not the medical care or treatment provider (physician, hospital, etc.).

When did managed care organizations start?

Managed care organizations (MCOs) began to proliferate during the 1980s, when the industry began to court employers (who pay the bulk of the nation’s health insurance premiums).

What is MCO plan?

MCO plans typically employ doctors and statisticians to assess computer-generated data, such as how long a heart attack patient should be hospitalized or what treatments are most effective for a particular illness or injury.

What are the benefits of Medicare managed care?

Benefits can include routine vision, dental and hearing services. Additionally, managed care plans offer prescription drug coverage. The cost of medications out-of-pocket can be financially exhausting. Medicare managed care plans can provide some relief.

What is managed care plan?

Managed-care plans or Advantage plans bundles all health-care coverage under one neat plan. MA plans decide on rate amounts, making prices different from plan to plan. Processing payments are done through the private plan, not Medicare.

What is Medicare Advantage 2021?

Updated on March 19, 2021. Medicare managed care plans are an alternative to Original Medicare. Otherwise known as Medicare Advantage plans with many plan types, most are either HMOs or PPOs. Managed-care plans provide benefits for gaps in Parts A and B coverage. These alternative health-care plans make up Part C of Medicare.

What is indemnity health insurance?

Before HMOs, PPOs, and others, Indemnity plans were the main plans to choose from. Indemnity plans pre-determine the percentage of what they consider a reasonable and customary charge for certain services. Carriers pay a percentage of charges for a service and the member pays the remainder.

Does an indemnity plan have a provider network?

Members will receive reimbursement for medical expenses (up to a certain amount). Indemnity plans have no provider network, members can visit the doctor (s) of their choice. Contrarily, managed care plans have a network (s) of providers, with different plan options.

Does managed care plan limit doctors?

On the other hand, managed care plans may limit beneficiaries to only the doctors within the plan’s network. If having the freedom to see any healthcare provider of choice is important, remember that Advantage plans limit provider options. While traveling within the country, managed care pays for emergency services only.

Is Medicare Supplement the same as Managed Care?

Managed-care plans and Medicare Supplement plans are not the same. This misconception is common. Both provide additional benefits to Original Medicare. However, they serve two totally different purposes. Managed-care plans or Advantage plans bundles all health-care coverage under one neat plan.

Is Medicare a QHC?

Medicare as Qualifying Health Coverage. The Affordable Care Act established the Individual Shared Responsibility provision that requires individuals to have qualifying health care coverage (QHC), also referred to as minimum essential coverage, qualify for an exemption, or make a payment when filing their tax return.

Does Medicare have a Marketplace?

The majority of individuals with Medicare coverage have both Medicare Parts A & B and do not have other private health insurance, like a Marketplace plan. Those individuals receive all their health insurance coverage through the Medicare program, whether they have Original Medicare or have a Medicare health and/or drug plan. ...

Does Medicare Part A qualify for QHC?

Medicare Part A (including coverage through a Medicare Advantage (MA) plan) qualifies as QHC. Beneficiaries who had 12 months of QHC in 2017 simply need to check a box on their tax return to indicate that they had health coverage.

Is Medicare Part A equitable relief?

CMS is offering equitable relief to certain Medicare beneficiaries who have premium-free Medicare Part A and are currently (or were) dually-enrolled in both Medicare and the Marketplace for individuals and families. Eligible individuals can request equitable relief at any time to enroll in Medicare Part B without penalty or to reduce their Part B ...

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