MediCare - Managed Care Insurance System

The HMO is the least expensive and most restrictive and common Medicare managed care plan.  There are four main restrictions:

• Care within the network only
  Each HMO maintains a network of doctors and healthcare  providers.
  The HMO member (i.e. patients) must receive care from only the provider in that network, except in emergencies.
• All care through primary care physician
  An HMO member(ie., patient) must select a primary care physician from the plan’s network.
  An HMO member may not see other doctors or providers  even from within the plan’s network  without a referral by the primary care physician.
• Prior HMO approval of some services
  HMOs may require that your primary care physician obtain prior approval from the plan for certain medical services the doctor may want to prescribe.
• Limited appeal rights
  Within every HMO plan, a member has a limited right to appeal the plan’s decisions.

If a member receives a service from a PPO’s network of providers, the cost to the member is lower than if the member sees a provider outside the network.

A PPO does not always require the patient to go through a primary care physician for referrals to specialists. PPOs usually tend to be more expensive than standard HMOs, charging both a monthly premium and a higher copayment for non-network services.

However, majority of people find that the extra flexibility in choosing doctors is an important comfort to them, and therefore worth the extra money.

plans allows you to select between an HMO or a PPO each time you need care.