Medicare Enrollment Means HMO, POS, PPO, MOOP & More

“Yes, Virginia. There is another acronym - as well as a Santa Claus. “

As we are into the Medicare Annual Enrollment Period, Oct 15 to December 7, I thought it would be useful to clarify some of these letters we see every day.

Networks

Many Medicare plans use a “network“ of doctors, specialists, outpatient facilities, hospitals and even dentists.

Remember - Insurance is a legal contract. The policy binds the company to provide coverage and benefits as stated. This includes how insurance works with medical providers. The doctors sign a contract with the insurance company as to what services they will provide and how they will get paid.

HMO – Technically, this stands for “ Health Maintenance Organization “. This first came into place in the mid-nineties as a way to more efficiently manage medical care and expenses. The term has evolved to mean that the insurance plan will be accepted by ONLY the contracted providers.

PPO - Preferred Provider Organization - The insurance companies contract with a defined network of providers – similar to HMO. AND with a PPO plan, you can see out of network doctors. Your copays, deductible and Maximum Out of Pocket – MOOP can be higher.

POS – Point of Service. This is somewhat of a hybrid between HMO & PPO. Your primary care doctor must be with the contract network as well as hospitals. You have expanded options for specialists like dermatology, physical therapy and the like.

A word about Dentists. This works in a similar way as other medical providers. The terms can be a little different, but the concept is the same In or Out of Network.

AND, Emergency Care is covered anywhere you would need it. The old Prudent Person rule applies. “A prudent person" would seek immediate medical care. From heart attack to broken arm to bee bites for those who are allergic.

MOOP – MAXIMUM OUT OF POCKET.

With Medicare advantage plans, you will have copays for doctors and specialist visits. Hospital stays are normally a defined dollar amount for a defined number of days.

Outpatient surgery, labs, therapy etc. are covered as copay or percentage. Only 2% or less of Medicare beneficiaries will reach the MOOP; the most common instance is where we have “Part B" medications, injections for chemotherapy.

Starting this year 2025, there is a separate MOOP for outpatient prescription medications. Part D Rx. This will increase to $2100 for 2026.

ACA – ObamaCare – Marketplace. As of this writing, the extension of “Enhanced Premium Tax Credits" has not been resolved. If Congress does not act, these premiums will more than double in price. If you make more than 400% of the federal poverty rate ($63,000 single, $128,000 family of four), you will lose any premium discount.

We have been working with clients on the Marketplace from day one. We can help with options.

Working together, we can evaluate what’s most important for your Medicare coverage. Please contact us today.

Dave Trout

Trout Insurance

Full Service, Local, Independent

29 N Main St. Weaverville, NC

828-279-4681

dtroutinsurance@aol.com

www.TroutInsurance.com