Medicare Coordinated Care Plans

A coordinated care plan is a classification of Medicare Advantage plans. They are provided by private insurance companies. Medicare coordinated care plans include health maintenance organizations, preferred provider organizations, Special Needs Plans and HMOs with a point-of-service option.

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What Are Coordinated Care Plans?

There are six types of Medicare Advantage plans. Four of these types fall under a category known as coordinated care plans.

Coordinated care plans include the most popular types of Medicare Advantage plans, such as health maintenance organization (HMO) plans.

All coordinated care plans have a network of health care providers approved by the Centers for Medicare & Medicaid Services.

You generally pay less out of pocket for care inside the provider network. Some plans also cover care received from out-of-network providers, but it will usually cost you.

For example, you may pay more for out-of-network care in a preferred provider organization (PPO) plan, while beneficiaries of an HMO plan may be responsible for all the costs if they receive care from an out-of-network provider.

Like all Medicare Advantage plans, coordinated care plans must provide the same basic coverage as Original Medicare (Parts A and B).

Most plans also offer prescription drug coverage, and some may offer additional benefits such as vision, dental and hearing care.

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Health Maintenance Organization (HMO)

Since 2007, about 63 percent of Medicare Advantage enrollees are in health maintenance organization plans, according to research by the Kaiser Family Foundation. Nearly 12 million people were enrolled in HMOs in 2017.

HMO plans are usually more cost effective than PPO plans. You will typically pay lower premiums and pay less out of pocket in exchange for less flexibility with your health care provider.

If you receive care from an out-of-network provider, you may be on the hook for most or all of the costs. Exceptions to this include emergency care, out-of-area urgent care and out-of-area dialysis.

Basics of HMO Plans
  • In most cases, you need to choose a primary care doctor.
  • A referral from your doctor may be required to see specialists or other providers.
  • You may be responsible for all the costs if you receive care outside the plan’s network of providers.
  • Medicare prescription drug coverage (Part D) is included with most plans.

Preferred Provider Organization (PPO)

One-third of Medicare Advantage beneficiaries were enrolled in a preferred provider organization plan in 2017, according to the Kaiser Family Foundation.

The key difference between PPOs and HMOs is that PPO plans cover a portion of the cost of care from out-of-network providers.

But more flexibility with where you can receive health care comes at a cost. Premiums and out-of-pocket costs can run higher with PPO plans.

Basics of PPO Plans
  • In most cases, you don’t need to select a primary care physician.
  • You have flexibility with which doctors, specialists or hospitals you can use, but health care providers outside the plan’s network will usually cost more.
  • You typically do not need a referral from a primary care doctor to see specialists or other providers.
  • Most plans include prescription drug coverage.

Point of Service (POS)

Point-of-service is a benefit option offered with some HMO plans. It is often referred to as an HMO-POS.

Think of it as a hybrid of HMO and PPO plans. You will designate a primary care doctor in the plan’s network of providers, but you have flexibility to seek care outside of the network.

It will usually cost less if you receive care from an in-network provider.

Basics of POS Plans
  • As with HMO plans, you usually have to select an in-network primary care doctor.
  • You have the option to receive care outside the plan’s network, but it may be limited to certain services or to a dollar amount.
  • Plans may allow you to see a specialist or other providers without a referral.
  • Like traditional HMO plans, most HMO-PPOs include prescription drug coverage.

Special Needs Plans (SNPs)

Medicare Special Needs Plans are health care plans designed for people with severe chronic conditions, those who are dual eligible for Medicare and Medicaid, and people living in an institution such as a nursing home or long-term care facility.

SNPs provide the same basic benefits as Original Medicare, but may operate under different rules, network restrictions and costs.

All SNPs provide Medicare prescription drug coverage, and most plans require you to designate a primary care doctor.

Basics of Special Needs Plans
  • To qualify, you must have a specific chronic condition, be dual eligible for Medicare and Medicaid, or need care at an institution.
  • Plans are not available everywhere and can vary by area.
  • You are required to have a primary care doctor.
  • In most cases, you need a referral to see a specialist.
  • Some plans may offer additional coverage such as vision and hearing care.
  • All plans must include prescription drug coverage.
Last Modified: September 15, 2021

8 Cited Research Articles

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