Module 2 - Medicare Advantage Coordinated Care Plans

Question 1

HMO enrollees must generally only use doctors and hospitals within the plan’s network (known as participating providers) for services to be covered. What are the exceptions?

Answer 1

The exceptions are;

1. Emergency services received outside of the plan network are covered.
2. When the enrollee is temporarily absent from the plan’s service area, dialysis services are covered outside of the network.
3. Urgently needed services received outside of the plan network are covered when the enrollee is temporarily outside of the service area or in rare circumstances when the network is not available.
4. If a needed specialist or a covered procedure is not available through the network, the plan will authorize out-of-network services.

Question 2

Do HMO Enrollees need to select a primary care doctor?

Answer 2

HMO enrollees may need to select a primary care doctor and may need a referral for specialty care

Question 3

Do some HMOs offer a Point of Service (POS) option?

Answer 3

Yes. Some HMOs offer a point-of-service (POS) option that allows enrollees to go to non-plan doctors and hospitals without receiving prior approval for certain services.

– Unlike a PPO, an HMO-POS plan may limit the services available out of the network or may put a dollar cap on the amount of out-of-network coverage.

– Cost-sharing is generally higher than for services obtained from network providers.

Question 4

Characteristics of a PPO are:

Answer 4

Under a PPO, enrollees”
– may get care from any provider in the U.S.> who accepts Medicare; they are not limited to network providers.

– PPO enrollees do not need a referral to see an out-of-network provider but are encouraged to contact the plan to be sure the service they wish to obtain out-of-network is medically necessary and will be covered.

– PPO enrollees usually pay higher cost-sharing amounts than they would pay in-network if they see an out-of-network provider.

NOTE: Regional PPOs are PPOs that are offered throughout an entire region, made up of one or more states.