HMO와 함께하는 메디케어프로그램 > 사회보장 최대혜택

 

An HMO, or Health Maintenance Organization is a managed care plan that sets guidelines for how your health care will be delivered. It's one of four plan options available for senior citizens under the Medicare Advantage Plan. Also known as a Medicare HMO, these plans provide an alternative to the traditional fee-for-service Medicare program. These organizations have contracted with the federal government to provide health benefits for Medicare recipients.

The Medicare Advantage Plan came about as the result of the Medicare Modernization Act of 2003. The act was instituted in an attempt to increase consumer participation in Health Maintenance Organizations. As a result of the change, HMO's were able to receive additional reimbursement from the government for services provided to senior citizens under this plan. While Medicare HMO's are government-sponsored programs, the actual health insurance policies are sold through private insurance companies.

 

 

Health Maintenance Organizations are considered managed care networks, meaning all aspects of a patient's care are contracted out and coordinated by the network. Patients can only choose from doctors and facilities who participate in their assigned network. Any referrals for specialists must be referred by the patient's primary care physician. Some Medicare HMO's do offer additional benefits outside of traditional Medicare coverage, like prescription, eye care and dental coverages.

As these are government-sponsored programs, these organizations are required to insure all Medicare-covered services. Participants under these plans have the same rights and protections as assigned under Medicare. Membership in Medicare Part A and Part B is a requirement. Participants must still pay premiums towards Part B coverage, however some HMO's will pay part of this premium amount, while others may charge an additional premium on top of the Part B requirement. As these plans are issued by private insurance companies, plan rates will vary from company to company.

 

 

Traditional Medicare and Medicare HMO's are structured differently in terms of available providers, benefits, out-of-pocket costs and affordability. A person's individual health care needs will determine which program will work best for her. There are no limits on available providers under a traditional plan, meaning participants can choose which doctor they want to see. Unlike Medicare HMO's, no referral from your primary care physician is required for treatment from a specialist.

The only significant difference in benefits between the two programs is traditional plans don't cover prescription, eye care or dental coverages, however an HMO will most likely charge an additional premium for these extras. Out-of-pocket costs under a traditional plan average out at 20 percent, while the other program sets fixed cost amounts, or co-payments for specific services. Overall, healthy individuals will most likely pay lower out-of-pocket costs under an HMO plan, whereas those who require specialty care, or require services from doctors outside of the network will pay higher costs under an HMO.