Category: Medicare Advantage

HMO vs PPO Which is Better?

HMO vs PPO Which is Better?

HMO vs PPO Which is Better?

HMO vs PPO Which is better in regards to health insurance, Medicare Advantage Plans and dental insurance

Insurance has changed a lot over the last 20 years, and there is no better example than the way we define and use provider networks. When you are looking at insurance plans, it’s important to compare HMO vs PPO. Which is better for you?

We are here to clear up the confusion, and quickly answer the most frequently asked questions in regards to what is HMO and PPO insurance, how the plans work, and where you will find HMO and PPO insurance plans.

If you are a Medicare user, you will run into HMO vs PPO in regards to choosing a Medicare Advantage Plan. You can learn more about Medicare Advantage Plans here.

What is an HMO?

To start, what is HMO health insurance? A HMO is a network of health care providers, set-up by a health insurance company, to offer services and benefits to its customers. (More at Healthcare.gov.)

What does HMO stand for? Health Maintenance Organization

How does an HMO work?

  • To start, when you are a beneficiary/member of an HMO, you have access to a specific set of healthcare providers in a specified geographical area. (For example, a city, counties or defined state(s).) These providers include doctors, healthcare professionals, specialists and hospitals.
  • You must use the HMO’s contracted providers to have your care paid for by your insurance plan. Moreover, if you go outside the plan for care, you will often have to pay the full cost of your care.
  • You can only go outside of your plan’s provider list in the case of an emergency.
  • With most HMO’s you need to have a Primary Care Physician (called a PCP). Your PCP takes care of your general health care and then refers you to specialists as needed.
  • So then, as a member of an HMO, if you need to see a specialist, your PCP with often have to refer you, to use one. However, in some states, and with some plans, the insurance companies have take away this requirement. As a result, it is important to check your specific plan’s requirements for seeing a specialist.
  • Finally, HMO’s are often concerned about prevention and keeping their member’s as healthy as possible to keep everyone’s costs down. For this reason, health maintenance organizations will often provide prevention based benefits and services to encourage safe and healthy behaviors among their members.

What is a PPO?

So, in regards to insurance, what is a PPO? A PPO is a type of insurance plan that uses a defined network of medical providers to meet your health care needs.

You pay a contracted rate (less than full price) to see network providers. However, unlike an HMO, with a PPO you can use doctors, clinics and hospitals outside the network at a higher cost. (More at healthcare.gov.)

What does PPO stand for? Preferred Provider Organization.

How Does a PPO Work?

  • First, with a PPO, you still have a network of providers to use that offer contracted prices to members of the PPO.
  • In contrast, you have more flexibility to go outside the network if needed to use uncontracted providers. You will most likely have to pay a higher percentage of the costs to use these providers, but the insurance companies will still pay something.
  • You can use any provider when the circumstance is deemed an emergency.
  • With most PPO’s, you do not have to have a referral to see a specialist.

What is the Difference Between HMO and PPO Insurance Plans

Both HMO’s and PPO’s have contracted networks of healthcare providers, clinics and hospitals where they will pay for some or all of your care. However, there are differences to consider:

  • First, HMO’s and PPO’s treat their out of network costs differently.
    • With an HMO, if you go “out-of-network” to see a provider, they may not cover any of your costs. Unless, it is an emergency situation.
    • With a PPO, the plan will most likely cover “out-of-network” provider/hospital visits, but at a lower percentage rate than their “in-network” providers/hospitals.
  • Second, the networks treat visits to healthcare specialists differently.
    • With an HMO, you will often need a referral to see a specialist.
    • With a PPO, you can most often just choose a specialist from the network provider list and make an appointment to see them without a referral.
  • Third, the PCP is usually the person making referrals in an HMO network. As a result,
    • The HMO’s often require having a primary care physician (PCP) on file for its members.
    • While the PPO’s usually do not have a requirement to name a PCP.

So, HMO vs PPO Which is Better?

After reading about the differences between HMO’s and PPO’s, it may seem like the PPO sounds hands down better than the HMO. Regarding, its freedom to see both in-network and out-of-network providers, and its options to see specialists without a referral, it does seem more flexible.

So then, why do people like HMO’s as well as PPO’s, and which one is right for you?

  • To start, HMO’s have changed a lot over the last years. Their networks have become more robust and their requirements less strict. In certain geographical areas, the HMO might include all the major hospital systems and the majority of providers. As a result, it may not matter to a person if they have a PPO or HMO, in regards to providers available.
  • Second, in some states, it is not necessary to get a provider referral to see a specialist in an HMO’s network. State laws often dictate how HMO’s work in this capacity, so it is important to learn how your area’s plans work.
  • Third, their may be a cost difference paid by members between an insurance company’s HMO and PPO plans. These costs include monthly premiums, max out of pocket costs, deductibles, and co-pays/co-insurances. When picking a plan, it often comes down to what is the more affordable option.
  • Finally, since HMO’s are often more focused on the wellness of their members, they might have other prevention benefits and services available to their members. PPO’s can sometimes have these services too, you will just need to do your homework to see what is included when shopping for a plan.

Going Deeper: HMO vs PPO Which is Better FAQ’s.

For those of you that have further questions, here are the most asked questions in regards to HMO and PPO insurance.

What does HMO POS mean? / What is HMO POS Medicare Advantage?

An HMO POS is a type of HMO network that allows more flexibility in seeing providers outside of the specified HMO provider list. POS stands for Point of Service.

According to Healthcare.gov, with an HMO POS, you will still need to choose a PCP (primary care physician) and they will still make specialist referrals for you. However, with a POS, if they want to refer you to a specialist outside of the HMO network, they can do so with the POS designation. Keep in mind, specialists and providers outside of the HMO network may still have higher out-of-pocket costs than in-network providers.

In a HMO POS Medicare Advantage Plan, you also have this ability to use providers who are “out-of-network,” but they may incur an increased cost.

What is Medicare PPO? / What is Medicare HMO?

PPO’s and HMO’s come into play in Medicare when you are using Medicare Part C – aka Medicare Advantage Plans.

Medicare Advantage (MA & MAPD) Plans are alternative plans offered by private insurance companies to take the place of Original Medicare. They often include drug coverage or Part D coverage (MAPD plans). They are approved by the Federal Government and cover everything that Original Medicare covers. In addition, they often offer benefits and services beyond what Medicare offers such as dental, vision and hearing benefits.

So then, what is a Medicare Advantage PPO plan or HMO plan?

What is Medicare Advantage?

Medicare Advantage plans are often HMO, PPO, or PFFS plans. (Additionally, they have special plans set up for people with special needs.) When you are choosing a Medicare Advantage Plan, you will need to consider everything we discussed about HMO’s and PPO’s as they will apply to these private insurance plans and how they set-up their provider networks.

Ok, then what is a PFFS Plan?

PFFS is a Private Fee-for-Service Plan. These plans also have networks that include a list of providers that have agreed to accept the plan. Moreover, you can see other providers, not on the list, as long as they agree to the plan’s terms and conditions and bill the plan directly. Original Medicare is an example of a PFFS plan.

What is HMO Medicaid?

Medicaid is provided to its recipients at a state level. Each state has to decide how to manage their Medicaid programs. These “managed care” options include choosing an insurance administrator to deliver healthcare services to Medicaid beneficiaries in a way that will “manage cost, utilization, and quality.” Often times the contracted insurance company will use an HMO model to structure their network of providers.

medicare and medicaid difference guide

In addition, if you are a “Dual Eligible” beneficiary – meaning that you qualify for both Medicaid and Medicare – then you have the option of finding a private insurer to manage your health care insurance. Each state has DSNP Medicare Part C (Medicare Advantage) providers that offer plans to dual eligible beneficiaries to help them manage the care between Medicare and Medicaid. These plans can also be HMOs or PPOs.

What is an EPO?

An EPO is an Exclusive Provider Organization. According to Healthcare.gov, “EPOs generally limit coverage to care from providers in
the EPO’s network (except in an emergency).”

What is PPO Dental Insurance? / What is HMO Dental Insurance?

Dental Insurance Carriers (aka Insurance Companies) set-up their provider networks similar to how medical companies set-up their networks. They have both DHMO and DPPO plans.

Just like in medical insurance, both DPPO’s and DHMO’s have provider networks, but HMO’s will typically only pay for services rendered by providers in the network. In addition, PPO’s will pay more of the costs for services provided by network providers, but will pay some percentage of costs out-of-network. For this reason, Dental HMO’s are usually less expensive than PPOs.

What is Better HMO or PPO Dental Insurance?

There are other differences between Dental PPO’s and HMO’s including deductible costs, and co-pays/co-insurances. When you are looking at dental plans in your area, you will need to decide what type of plan most affordably meets your dental care needs.

Sometimes this will be an DHMO and other times, this will be a DPPO, so compare costs, provider networks and types of dental services covered before buying a policy. Here is a good article for more detail on dental insurance network types to help you decide what is best for you.

What is Preferred Provider Organization?

Also known as a PPO, a Preferred Provider Organization is a type of insurance plan that provides a network of healthcare providers, offices and hospitals for its members to use at contracted costs. In addition, it provides the flexibility to use providers outside of its networks if needed, but at a higher cost to the members.

Then, what does preferred provider mean?

Preferred provider means that a particular doctor, specialist, clinic, hospital or other healthcare professional or facility is a part of your insurance provider’s network. They will offer a contracted (most likely discounted) rate for you to use their services while on your PPO insurance plan.

What is the largest PPO network?

The largest PPO Network in the United States is MultiPlan.

What is MultiPlan PPO?

Multiplan is not a “type” of healthcare insurance. They are a third party company that helps insurance companies “manage the cost of care, improve their competitiveness and inspire positive change.” You do not have a Multiplan PPO, you have a PPO that uses Multiplan.

What is a Regional PPO?

We often hear the questions, “what is a Regional PPO?” and “what is a Regional PPO Medicare Advantage Plan?” Regional just refers to the service area for the PPO. Members will have access to providers in the PPO’s specified region.

What is Health Maintenance?

“Health Maintenance” refers to a system of prevention. In insurance terms, it refers to an insurance network plan with a focus on keeping medical costs down by keeping members healthy with lower cost preventative care options.

The thought is “an ounce of prevention” will lead to significant cost savings on unused healthcare dollars down the road.

So then, what are the benefits for providers who use HMO model?

Providers who are a part of the HMO model have benefits of being a part of a network that pays them based on a contracted fee. Each network will arrange the contracts differently. However, the providers will know that they have access to the insurance carrier’s pool of members to service for their healthcare needs.

HMO vs PPO Which is Better Summary

In conclusion, whether a PPO or a HMO is “better” all depends on your needs and the plans available in your area.

If we missed any questions in “HMO vs PPO Which is Better” you may have, please drop us a note in the comments and we will do the best to answer them!

All the best. Carly and the MLH Team

How Long Does Medicare Pay for Rehab?

How Long Does Medicare Pay for Rehab?

How Long Does Medicare Pay for Rehab?

How Long Does Medicare Pay for Rehab

How Long Does Medicare Pay for Rehab? It depends on what Medicare Plan you have.

Medicare often pays for at least part of medically necessary rehab.

However, how it pays, and how much it pays, for your rehab is dependent on what type of care you need and what kind of Medicare plan you have.

Let’s look at the various types of rehab and how:

  • Original Medicare,
  • Medigap, and
  • Medicare Advantage address coverage.

Original Medicare Rehabilitation

Rehab, or Inpatient Rehabilitation Care, is part of Medicare Part A or “Hospital Insurance.” To learn more about what Part A covers, click here.

Rehab administered in an outpatient setting or by doctors / medical providers can be covered by Part B when considered necessary by Medicare Standards. One example of a covered program is Cardiac Rehabilitation Programs.

“Medically Necessary”

Original Medicare will pay for part of your rehab in most cases if your care is considered “medically necessary” by CMS (Center for Medicare and Medicaid Services) standards.

According to CMS, medically necessary rehabilitation requires:

  • certification by a doctor that you have a medical condition that requires rehab
  • continued professional medical supervision
  • coordinated care from doctors and therapists

How Many Days does Medicare Pay for Rehab?

If you only have Original Medicare, you will have costs associated with rehab for each benefit period.

  • For the first sixty days, a deductible will apply (in 2020, $1,364).
  • After that, a $341 coinsurance will apply to days 61-90, and $682 coinsurance from day 91 and beyond.
  • Finally, if you are going beyond 91 days in rehab, you will only have 60 more “lifetime reserve days” for coverage. What this means is that Medicare will only cover 60 rehab days total in your lifetime after you hit the 90 benefit period limit. These lifetime days do not start over each year. As a result, if you run out of lifetime reserve days, you will be paying 100% of all costs for rehab when you run out.

For more information on inpatient rehab, please visit this medicare.gov page.

Medicare Supplements (Medigap)

Medicare Supplements are designed to pick up the costs that Original Medicare does not cover (such as deductibles, coinsurance and co-pays.)

Click here to read more about Medicare Supplements.

There are some Medicare Supplements that pick up just about all costs that Medicare does not pay. (As long as they are “covered services.”) You can consult this chart to see what plan pays what.

Medigap Plan Letter Policy Chart - what supplements cover what services
CLICK HERE to see more about the various Medigap plans and what they offer.

Medicare Plan F and Plan G offer the most extensive coverage and among the most popular plans.

Medicare Advantage Rehab Coverage

how to apply for medicare article - medicare enrollment questions and answers

Private insurance companies run Medicare Advantage plans. They are designed to “replace” Original Medicare. They cover at least what Original Medicare covers plus they offer additional coverage and extra benefits and services to their beneficiaries.

Each Medicare Advantage Plan will be different in regard to their Medicare rehab coverage. However, they most often offer additional coverage or a different structure as to how they cover rehab days – both inpatient and outpatient.

Additionally, all Medicare Advantage Plans (also called MA / MAPD plans) are required to have a “max-out-of-pocket” limit for each annual benefit period. This means that you will not pay more than that predetermined amount each year for your covered health services.

the most frequently asked medicare questions or faqs

Now that we have looked at the various plans and how long they cover rehab, let’s look at a few specific examples that Medicare addresses.

Does Medicare Pay for Physical Therapy?

Sometimes, when people ask if Medicare pays for rehab, they are referring to outpatient physical therapy.

Medicare covers some costs for outpatient physical therapy when it is considered “medically necessary” as we defined earlier in this article.

Medicare Part B helps pay for physical therapy, and if you only have Original Medicare, you will pay 20% of your medical costs.

How Long Does Medicare Pay for Physical Therapy?

According to CMS, “Medicare law no longer limits how much it pays for your medically necessary outpatient therapy services in one calendar year.”

Finally, always remember to make sure that your physical therapy is considered both medically necessary and a Medicare covered service. If it is not, you may end up paying for all of it.

Need more info? Allow us to direct you to the correct pages on the government website for information on:

How Long Does Medicare Pay for Cardiac Rehab?

If you have recently had a heart attack or some other cardiac event (see here for more information on what “events CMS covers), Medicare will cover most costs for Cardiac rehabilitation programs. These programs usually are covered for as long as they are needed.

Medicare covered costs can include both regular cardiac rehab and “Intensive Cardiac Rehabilitation” Programs (ICR).

According to CMS, programs can address exercise, education and counseling in some form, and can either be held in an outpatient hospital setting or at a doctor’s office.

In regards to costs, just remember…

  • Original Medicare will cover 80% of approved medical bill amounts under Part B. (Part B deductibles may apply).
  • If you have a Medigap Plan (aka Medicare Supplement) then that plan will pick up additional costs according to your plan’s letter specifications. (See the Medigap chart above or visit our Medigap Page for more information.)
  • Or, if you have a Medicare Advantage Plan, your plan will list out how it covers cardiac rehab costs and what your copayments will be, if any.

How Long Will Medicare Pay for Nursing Home Rehab?

If you need rehab that extends beyond a stay as an inpatient at a regular hospital, your doctors may transfer you to a “Long-Term Care Hospital” (LTCH). Long-Term Care Hospital stays are different than living in a Long-Term Care facility (also called a nursing home). They are still considered a hospital setting, so they are covered by Medicare Part A.

Under Original Medicare, your coverage lengths and payment amounts are the same as the inpatient rehab amounts we detailed out above in the section, “How Many Days does Medicare Pay for Rehab?.” Or, you can find them on the government website here.

However, your benefit period does not start over if you are transferred from one hospital to another (including a LTCH). So, you will not have to pay another deductible.

Conclusions

We understand that Medicare rules and costs are often confusing. This is especially true when you are confronted with rehab options. Your coverage lengths and costs will often be different depending on how you have your Medicare coverage set-up.

If you need more help in answering questions regarding your specific plan, you can reach out to your insurance agent or plan directly. If you are looking for an agent, you can contact us for help.

What is MAPD?

What is MAPD?

What is MAPD?

What is MAPD + PDP+ Medicare Jargon Made simple

There are a lot of acronyms in Medicare, and even more in insurance. We know, it can get very confusing when you are not hip to the “Medicare/ insurance world” lingo. As a result, one of the most repeated acronym questions we hear is: What is MAPD?

Medicare MAPD plans are private insurance plans offered by Insurance Carriers to replace Original Medicare. Also called Medicare Part C, they offer a single payer option to beneficiaries. In addition, they offer extra benefits to members above and beyond what is covered in Medicare Part A and Part B. Finally, they also include a Part D drug plan.

What does MAPD Stand for?

MAPD Stands for: Medicare Advantage Prescription Drug.

If the plan does not offer drug coverage, then it is just called a MA (Medicare Advantage) Plan. As mentioned, these plans are also called Medicare Part C, and insurance companies offer Medicare MAPD plans with extra benefits to take the place of Original Medicare.

What Do Medicare Advantage Plans Cover?

Medicare Advantage Plans are regulated by the CMS (Centers for Medicare and Medicaid Services). This agency makes sure that every plan offers at least the same standards of care and coverage that Original Medicare offers. Most plans offer additional benefits, not covered by Original Medicare, such as vision, dental, hearing and even gym memberships such through organizations like SilverSneakers or Renew Active.

Medicare Advantage Plans are often set up as managed care plans with networks of doctors and hospitals members have access to. To learn more about how these networks work, please read, HMO vs PPO – Which is Better?

Costs of MAPD

Medicare Advantage Plans often come with lower premium costs than Supplement Plans. Some of them even offer “zero premium” options. They are not technically “free” because everyone still has to pay their Medicare Part B Premiums directly to the government each month.

However, they are low cost options because the government is paying the insurance company to take beneficiaries onto their books and off the government books. Essentially, the Medicare Advantage Insurance companies are replacing beneficiaries Original Medicare with their Part C plan and becoming a single-payer.

PDP vs MAPD

PDP is an acronym to Prescription Drug Plan. We also refer to it as Medicare Part D. You can read more about PDP Drug Plans here.

Similarities between PDP and MAPD Plans

  • Just like Medicare Advantage (Part C), PDP plans are not administered by the U.S. government, but instead by private insurance companies. Just like MAPD Insurance plans, you can shop to find the best PDP plan for your needs each year.
  • And also, just like Medicare Advantage Insurance plans, you do not have to go through medical underwriting to be accepted into a Part D plan.

Differences Between Medicare Advantage and Part D Plans

  • First, if you have Original Medicare, you will need a PDP plan in addition to Parts A & B to cover your prescription drugs needs. They are not included.
  • Additionally, beneficiaries on Original Medicare + a PDP Part D Drug Plan often also have a Medigap Plan (Supplement) to cover the 20% of costs, co-pays and co-insurances that Medicare does not cover.
  • MAPD Healthcare Insurance Plans, on the other hand, include all three of these options in one (Parts A + B + D).
  • As a result, you will not need a standalone PDP plan or a Medigap Plan in addition. All you need is your MAPD Plan (aka Medicare C).

Further Medicare Reading

How to Choose A Medicare Plan
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The Medicare and Medicaid Difference Guide helps you understanding both services, so you can make the best decisions for yourself and your loved ones.

The United States has two separate national health care systems: Medicare and Medicaid. The government created the two programs for two different kinds of people. However, they often overlap. Let’s look at both programs, including their similarities and difference. We will also look at who needs or qualifies for each program.

Let’s Start with Medicare vs Medicaid.

What is Medicare?

Medicare is the U.S. national health care program that provides seniors age 65 and older, and some disabled people, with health insurance.

The U.S. government started the program in 1966. The Centers for Medicare and Medicaid Services runs these programs. Medicare also covers people with end stage renal disease and amyotrophic lateral sclerosis.

Medicare does not cover all of the costs associated with health care. As a result, people with Medicare will also use a Medicare Supplement Insurance Plan (Medigap Plan) or a Medicare Advantage Insurance Plan to round out their care coverage.

Please read our Ultimate Guide article on “What is Medicare.

https://medicarelifehealth.com/glossary/medicare

What is Medicaid?

Medicaid is the United States National Health Care System that provides health coverage to over 64.7 Million People.

The program was created for people with low-incomes that cannot afford, or do not have access to, private healthcare insurance.

https://medicarelifehealth.com/glossary/medicaid

How are the programs similar?

Medicare vs Medicaid Pin

The programs are both National Health Care Systems. In fact, they are the only two nationalized heath care systems the United States has. Many other countries around the world have much more extensive national coverage for their citizens. The U.S. has a limited program for specific age, income, and health groups, and the rest of the country relies on private health insurance.

In addition, both programs cover specific hospital services, doctor services, and other health care related services.

Medicare has four parts. First, Medicare Part A, also known as “Hospital Insurance,” helps with coverage regarding: inpatient care, home health care, nursing facilities, and hospice.

Second, there is Medicare Part B, also known as “Medical Insurance.” Part B helps with coverage related to doctor and other provider services, including: doctors visits, health care providers, outpatient, prevention services, and medical equipment. Medicare Beneficiaries pay for Part B.

Finally, Medicare has a Prescription Drug Program that is administered by private insurance carriers. Click here to lean more about What Medicare Covers and Medicare Parts A, B, C and D are.

Both Medicaid and Medicare Advantage Plans can be set up as managed care plans with networks of doctors and hospitals members have access to. If you would like to learn more about how these networks work, please read, HMO vs PPO – Which is Better?

How are the programs different?

One of the biggest differences between the two programs is who runs them. Medicare is run on a national level, by the Federal government. On the other hand, Medicaid is run by each state individually.

Of course, the biggest difference is the the different populations the programs serve:

  • Medicare – For Seniors over age 65, and some disabled people
  • Medicaid – For people with low income and few resources

Medicare and Medicaid Differences in Beneficiaries – Who Gets What Program?

The U.S. government created Medicare and Medicaid to take care of different “vulnerable” populations – the poor, the disabled, and the elderly. Let’s look at each program and population.

Who should get Medicare?

Anyone who is a citizen or qualified resident of the U.S. can enroll in Medicare when they turn 65 years old. There is a seven month window of time starting three months before turning 65, the month of your birthday, and then three months after your birthday month.

How do I Sign-up for Medicare?

First, you may be automatically signed-up if you are already receiving Social Security (SS) or Railroad Retirement (RRB).

Second, if you are not already receiving SS or RRB benefits, you must sign up for it when you turn 65 years old.

Conversely, if you are not ready for Medicare when you turn 65, you must notify the government that you want to delay your benefits. If you do delay, it must be because you have credible coverage in place. An example of this would be an employer plan.

Click here to read more about Medicare, including where to go to enroll.

From Our Article What is Medicare? A Guide to All Medicare Basics

Supplemental Medicare Insurance Options

Medicare picks up about 80% of the health care costs for its beneficiaries. For the other 20%, seniors turn to either Medicare Supplements (aka Medigap Plans) or Medicare Advantage Plans. Click here to read our article on Medicare Advantage vs. Medigap, or see the informational articles below.

What is Medicare Advantage?
What are Medicare Supplements_

Who should get Medicaid?

Medicaid is for people with limited income and resources. Medicaid is run on a state level, not on a federal level. As a result, in order to qualify for Medicaid, you will need to determine what your state defines as a qualifying income level.

How Do You Enroll in Medicaid?

Again, since Medicaid is run by State Governments, you will need to contact your state’s agency to start see if you qualify to enroll.

You can find a list of State Agencies here on the Medicaid.gov website.

Who Can Get Both Medicare and Medicaid?

People of any age who have certain qualified disabilities and people over 65, who are also below their states Medicaid income levels, can qualify for both Medicare and Medicaid.

For example, Henry is a 55 year-old disabled man who is also unemployed and living below the poverty level set by his state. Consequently, he would most likely qualify for both Medicaid (because of his income level) and Medicare (because of his qualified disability).

People that qualify for both programs are called “Dual Eligible.”

Who Can Help?

Navigating one (let alone both) of these systems can be confusing. But there is help available.

  • If you need help enrolling in Medicare, then you can contact CMS and Social Security in the following ways:
  • Finally, if you need help finding a Medicare Supplement or Medicare Insurance Plan, or if you are dual eligible for both Medicare and Medicaid, then please contact an Insurance Agent. An Independent Medicare Insurance Agent will help you explore your options, and help you make the right choice for your unique situation.

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Renew Active vs Silver Sneakers

Renew Active vs Silver Sneakers

Renew Active vs Silver Sneakers

Renew Active vs Silver Sneakers

Does it sometimes seem like Medicare and Insurance companies are trying to make things as complicated as they possibly can? Just when you think you have Medicare Advantage down, something else comes up! For example: Renew Active vs Silver Sneakers.

Not so very long ago, there was one main senior fitness program when you joined a Medicare Advantage Plan: SilverSneakers®. Then, in January 2019, one carrier dropped SilverSneakers and replaced it with Renew Active™. Many people were concerned when this first happened. However, it now seems like Renew Active is a reasonable replacement.

Who is Affected?

The people affected by the change to Renew Active are those that are a part of a Medicare Advantage Plan that has the program as a benefit. (In addition to those people considering whether or not to join their plan.) The majority of the other Medicare Advantage plans still use Silver Sneakers as their main plan.

How to Make a Decision?

If you are trying to decide on a Medicare Advantage Plan in your area, Renew Active vs Silver Sneakers may play a part in your decision.

Let’s take a quick look at the two programs, how they are similar or different, and whether or not there are advantages to either one.

What is Silver Sneakers?

what is Silver Sneakers Senior Fitness

SilverSneakers® is a fitness and wellness program for seniors age 65 and up. It includes free gym memberships across the country, and it is included with many Medicare Advantage Plans.

Click here to read our article: What is Silver Sneakers?

What does a SilverSneakers Membership Include?

  • LOCAL GYM MEMBERSHIPS: Silver Sneakers has an extensive list of gyms that participate in their program that offers free gym memberships to seniors. Their website boasts having more gym facilities than there are Starbucks locations in the U.S. (at over 16,000).
    • If you are a part of a Medicare Advantage (MA) program that uses Silver Sneakers, then you can access the gyms in their network at no cost. You can use as many of these facilities as you like while you are a part of your MA plan.
  • ONLINE FITNESS CLASSES: If you prefer to workout at home, or do not have a physical location close to you, SilverSneakers offers online fitness classes.
  • APP: They also have an app to help you track your fitness goals and schedule your fitness plans. The app can also help you locate participating locations.

What is Renew Active?

Renew Active™ is another program offered by a carrier with select Medicare Advantage plans. It also offers access to gyms and fitness places across the country.

What does a Renew Active Membership Include?

  • GYM ACCESS: When we looked into all the benefits offered by Renew Active, we found the standard access to local gyms.
  • BRAIN TRAINING: Interestingly, they also offered a unique feature of online brain training. The company partnered with BrainHQ to offer an app to keep your brain sharp with games and tools available on a PC or mobile device.
    • The BrainHQ service is available for purchase from $8-$14 a month, so getting this included with your Renew membership does seem like a good deal.

Renew Active vs Silver Sneakers: How are they Similar?

renew active vs silver sneakers pin

When comparing Renew Active vs Silver Sneakers, you will find they are very similar in their main functions.

  • To start, both programs offer free gym memberships at local fitness facilities.
  • In addition, you can sign-up for multiple fitness locations with both memberships.
  • Both plans offer at-home options for people that are too far away from any participating facilities.
    • For at home options with Renew Active you must call their customer service phone number. Apparently, you can find this on the back of your health plan member ID.
    • You can find SiliverSneakers at home programming information online here.
  • Finally, Medicare Advantage Plans include one of these programs at no additional cost to plan members.
    • (Some Medigap plans in certain states may have access to some sort of fitness benefit, but that is all dependent on the insurance company and the service area. This is not near as common. Mostly fitness plans are an extra benefit of Medicare Advantage plans.)

How They are Different: Renew Active vs Silver Sneakers

renew active vs silver sneakers comparison chart or checklist from medicarelifehealth.com
  • The first difference we see at this time is Silver Sneakers seems to be in more facilities.
    • SilverSneakers boasts over 16,000 locations.
    • At the start of 2019, Renew Active mentioned over 7,000. However, it seems like their program has grown since that mention.
    • Check the location searches for both programs to make sure your gym preference is covered.
  • The second difference is that Renew Active has an online brain training application included, and Silver Sneakers does not (at the time I am writing this article).
    • The BrainHQ app seems to retail at $8-$14 a month if you wanted to buy it separately, so that does suggest added value.
    • We have not tried this app, and could not find a lot of research or reviews on the platform at the moment. Please leave a comment if you find something useful!
  • In our Renew Active vs Silver Sneakers comparison, the third difference we see is that Silver Sneakers has an good list of online classes.

What’s Better About Silver Sneakers?

To start, if you are someone who likes to do workouts at home, and likes to stream different workouts online, Silver Sneakers has more to offer you in this area. Their online “on-demand” workout section boasts hundreds of online workouts available.

Also, Silver Sneakers seems to have the larger network of physical fitness facilities at this time.

Finally, multiple Medicare insurance company plans use SilverSneakers. This means your coverage might not change if you change Medicare plans.

What’s Better About Renew Active?

Renew Active is only associated with one carrier’s Medicare Advantage Plans. It’s major advantage over SilverSneakers seems to be the access to BrainHQ training games. It’s network might be a bit smaller than SilverSneakers, but it is still impressive and very useful.

Should Renew Active vs Silver Sneakers be a Deciding Factor on Your MA Plan?

In my opinion, there are much more important factors to consider when choosing a Medicare Advantage Plan than Renew Active vs Silver Sneakers. Your network access to doctors and medical providers should be your first consideration. Your drug plan and hospital facilities and costs should also be more important.

However, if all your plans seem comparable, your decision might include the convenience of using a local wellness facility, streaming exercises at home, or participating in brain health activities.

In this case, it is a great idea to hop onto the facility location tools and online resources for both Renew Active and Silver Sneakers. You can then make sure the program you choose covers your gym or desired services.

What is Silver Sneakers?

What is Silver Sneakers?

What is Silver Sneakers?

what is Silver Sneakers Senior Fitness

Maybe you just overhead your neighbor talking about his free gym membership, or maybe your doctor asked you if you are a SilverSneakers user. You might then be wondering, just what it Silver Sneakers?

SilverSneakers(r) is a fitness and wellness program for seniors age 65 and up. It includes free gym memberships across the country, and it is included with many Medicare Advantage Plans.

NOTE: If you are a part of AARP’s Unitedhealthcare’s Medicare Advantage Plans, then you will be a part of Renew Active. This is a similar program, but has several differences you can read about here.

Renew Active vs Silver Sneakers

What is Included in a Silver Sneakers Membership?

  • LOCAL GYM MEMBERSHIPS: Silver Sneakers has an extensive list of gyms that participate in their program that offers free gym memberships to seniors. Their website boasts having more gym facilities than there are Starbucks locations in the U.S. (at over 16,000).
    • If you are a part of a Medicare Advantage (MA) program that uses Silver Sneakers, then you can access the gyms in their network at no cost. You can use as many of these facilities as you like while you are a part of your MA plan.
  • ONLINE FITNESS CLASSES: If you prefer to workout at home, or do not have a physical location close to you, SilverSneakers offers online fitness classes.
  • APP: They also have an app to help you track your fitness goals and schedule your fitness plans. The app can also help you locate participating locations.

What you Need to Know About Silver Sneakers

First, there are a few things you need to know to get started. Here is an overview and some frequently asked questions about the program.

How do I know if I am a member of SilverSneakers?

Well, if you are part of a Medicare Advantage Plan, then there is a very good chance you are already a part of the program.

To check on your eligibility, click here.

Where can I find participating gyms and wellness facilities?

As an overview, SilverSneakers tries to be in as many convenient fitness facilities as possible. Moreover, they are doing an excellent job of reaching this goal! Right now, they are in over 16,000 fitness facilities.

Here is the official link to search for a participating fitness facility near you.

What if there are no facilities close to me?

If you are in a smaller town or rural area, there might not be a class or gym close to you. However, even if there is not a Silver Sneakers contracted location close to you, you can still participate. The program features online classes and workout kits.

Do I have to take the Silver Sneakers Classes?

what is silver sneakers?

Often, people will ask me if they have to attend the SilverSneakers branded classes at the gym. The answer is no. The program gives you access to the whole facility. This includes Silver Sneakers classes, but also all the other classes at the gym. You can also just go walk on the treadmill or lift weights.

2020 Part B Deductible

2020 Part B Deductible

2020 Part B Deductible for Medicare

2020 Part B Deductible

The 2020 changes for Medicare were released this month. The 2020 Part B Deductible is just one of the increases you will see.

The Centers for Medicare & Medicaid Services (CMS) released their updates for the coming year in a press release – 2020 Medicare Parts A & B Premiums and Deductibles. Let’s look at what is changing.

Part B Deductible for 2020

  • In 2020, the Medicare Part B Deductible will be $198.
  • In contrast, the deductible was 185 for 2019.
  • This is an increase of $13.

Part B Premiums for 2020

  • In 2020, the Medicare Part B Monthly Premium will be $144.60.
  • In contrast, the premium was 135.50 for 2019.
  • Consequently, this is an increase of $9.10.

Why are the Part B Deductible and Premiums Increasing in 2020?

The CMS adjusts the deductibles yearly, in accordance to the Social Security Act. Moreover, the increase reflects national healthcare trends.

In addition, the CMS has stated that the rate hike is mostly due to the increased use and cost of physician- administered drugs. Part B covers Physician-administered drugs.

What Part B Covers

Medicare Parts A B C D Explained

As a reminder, Medicare Part B covers:

  • Physician and Provider Services
  • Outpatient Services
  • Home Health Services
  • Durable Medical Equipment
  • Other non-hospital health services

To learn even more about the parts of Medicare and what they cover, you can see our infographic and discussion here.

Who Pays the Part B Deductible?

  • If you have Original Medicare only, you will pay the Part B Deductible.
  • In addition, if you have a Medicare Supplement that does not cover the Part B Deductible, you will pay it.
  • Some Medicare Advantage Plans have you cover the Part B deductible. This will be stated in your Summary of Benefits. However, 2020 plans have already been released, so deductibles are already set for the new year and will not be affected by this increase.

As of 2020, new beneficiaries to Medicare will not be able to choose a Medicare Supplement Letter Plan that covers the Part B Deductible. For example, Plan F covers the deductible, so seniors new to Medicare in 2020 and beyond will not be able to pick Plan F. Seniors that are already on these letter plans can keep them. Read more about this topic here.

Will the Changes Affect Part C or Part D costs?

No, these deductible and premium increases will not affect Part D Drug Plans or Part C Medicare Advantage Plans. The premium costs and the deductibles have already been set for the coming year. As a result, they are not affected.

According to the CMS press release,

As previously announced, as a result of CMS actions to drive competition, on average for 2020, Medicare Advantage premiums are expected to decline by 23 percent from 2018, and will be the lowest in the last thirteen years while plan choices, benefits and enrollment continue to increase. Premiums and deductibles for Medicare Advantage and Medicare Part D Prescription Drug plans are already finalized and are unaffected by this announcement.

CMS Press Release, Nov 2019

That is extra good news for those on Medicare Advantage Plans that have their deductibles satisfied with their plan. Some Medicare Advantage plans have a zero dollar deductible for their whole plan. These plans bundle Parts A & B and have the option of including the Part B Original Medicare deductible or covering it themselves.

Income Adjustments to Part B Premiums

There are no income related adjustments to the Part B Medicare Deductible. However, there are income related adjustments to your Part B Premiums.

  • First, the standard 2020 Part B premium of $144.60 applies to those with income less than or equal to $87,000 a year ($174,000 joint income).
  • Second, if you claim income between $87,000 and $109,000 ($174k-$218k joint), you will pay $202.40 a month.
  • Third, if you claim income between $109,000 and $136,000 ($218k – $272k joint), you pay $289.20.
  • Fourth, if you claim income between $136,000 and $163,000 ($272k – $326k joint), you pay $376.00.
  • Fifth, if you claim income between $163,000 and $500,000 ($326k – $750k joint), you pay $462.70.
  • Finally, if you have income greather than or equal to $500,000 ($750k+ joint), then you pay 491.60.
  • Click here if you need to see a table for premiums for spouses that file separate returns.

Are there Changes to Part A?

Yes, there are also changes to Medicare Part A. If you have a Medicare Supplement Plan, depending on which Letter plan you have, your supplement will continue to pick up these costs.

If you have a Medicare Advantage Plan, your plans benefits will still apply to you instead of the Original Medicare benefit structure. 2020 plans have already been released, so you will not be affected by these changes.

However, if you have Original Medicare only, you will want to take a look at the Part A changes that affect you here.

Further Reading

If you would like to learn more about Medicare we Suggest the following articles:

This Tool Kit answers your questions regarding Medicare Information, Medicare Supplements, Medicare Advantage, and Prescription Drug Plans. Discover what products are right for you and how to sign-up for them. 

Medicare 101

Read about basic Medicare Information. What is Medicare Part A? Part B? Get answers to your basic Medicare questions.

Medicare Supplements

What is a Medicare Supplement and how do I choose the best one for me? 

Medicare Advantage

What is Medicare Advantage and when is it, and what plans are, best for my situation?

Prescription Drug Plans

When do I need a drug plan and what do I need to look for in a good plan?

Medicare Advantage vs Medicare Supplements

What plan type is best for my situation and what do I need to consider when choosing.

Most Asked Medicare ?s

Answers to your questions and answers to questions you should be asking.

Medicare Open Enrollment

Medicare Open Enrollment

Medicare Open Enrollment

medicare open enrollment 2019

Medicare Open Enrollment runs from October 15th to December 7th. These are the same dates every year.

What is Medicare Open Enrollment?

Also called AEP – Annual Enrollment Period is the time of year Medicare Beneficiaries can make changes to their Medicare Advantage Plans and Prescription Drug Plans.

Information for new plans starts to become available each year on or around October 1st, but changes can not be made until AEP actually starts on October 15th.

What Changes Can you Make During the Annual Enrollment Period?

  • If you are in Original Medicare, you can join a Medicare Advantage Plan during this time.
  • You can also join or switch Part D Prescription Drug Plans.
  • In addition, if you have a Medicare Advantage Plan, you can switch to another plan.
  • Finally, you can drop a Medicare Advantage plan to return to Original Medicare during this time.

Are Medicare Supplements Affected by Medicare Open Enrollment?

This enrollment period does not apply to Medicare Supplements (Medigap) Plans. You are free to change these plans when you please. However, if you are outside of a Special Enrollment Period (SEP) then you will need to go through medical underwriting to get into a new Medigap Plan. Medical Underwriting usually entails answering basic health questions by phone or in person with an agent.

What is the January – March Open Enrollment Period?

Sometimes also called Open Enrollment, the government created a new time period that runs from January 1st to March 31st each year where you can make limited changes. According to the Medicare and You Book,

If you’re in a Medicare Advantage Plan, you can make a change to a different Medicare Advantage Plan or switch back to Original Medicare (and join a stand-alone Medicare Prescription Drug Plan) once during this time. Any changes you make will be effective the first of the month after the plan gets your request.

Medicare and You 2020

The important thing to note here, is that you can only make ONE change during this time. Lawmakers created this time period to give you the opportunity to fix any problems you may have found in your current plan or any new plan you may have adopted.

Railroad Medicare

Railroad Medicare

Railroad Medicare – What You Need to Know

Here is what you need to know about Railroad Medicare Benefits to be successful in your retirement planning.

Introduction to Railroad Medicare

Railroad Medicare Benefits and Choices at MedicareLifeHealth.com

So, you are retiring from the Railroad? Congratulations! Mostly, your options for Medicare planning will be the same as everyone else’s. Our articles on Medicare Basics, Medicare Supplements and Medicare Advantage will all apply to you.

However, there are just a few differences between Social Security and the Railroad when it comes to Medicare. Let’s look at what these similarities and differences are.

What is the Same

Signing-up

  • Already Retired: Signing-up for Medicare is the same on SS or RRB. If you are already receiving benefits from Social Security or the Railroad you will be automatically enrolled in Medicare Part A and Part B. You can then decline Part B if you want to. (Read about declining Part B here.)
  • Not Yet Retired or Not Receiving Benefits: For those of you that are not already retired and/or not yet receiving benefits, you will need to notify the local Railroad Board (RRB) office before you turn 65 that you would like to sign-up for Medicare. You can sign-up up to 3 months before you turn 65, and even if you are not planning on retiring at 65.

Your Medicare Path Choices

Just like Social Security Medicare, you will have two options for setting up your Medicare:

  • Original Medicare: You have the option of choosing to keep Original Medicare and then enrolling in a stand-alone Part D Drug Plan. In addition, you can then add a Medicare Supplement (Medigap) plan to pick up the costs Original Medicare does not cover. You can read more about Original Medicare here.
  • Medicare Advantage: You also have the option of moving to a “bundled” Medicare Advantage plan. These plans are run by private insurance companies and bundle together Parts A, B & D all into one plan with one point of contact. They are also called Medicare Part C. You can read more about Medicare Advantage here.

You can read about the difference between Original Medicare and Medicare Advantage here.

What is Different

Part B Claims Processing

The major difference in Medicare for Railroad Board vs Social Security, is how the Part B claims are handled. Unless you are enrolled in a Medicare Advantage Plan (where the private insurance company you use handles all of your Medicare claims), you will deal with a different claims handling entity than those enrolled in SS Medicare.

The Railroad Medicare program uses an outside company for medical insurance claims that fall under Part B services. (Read more about the different parts of Medicare and what they cover here.) This company Palmetto GBA. They are a subsidiary of Blue Cross and Blue Shield. You will need to submit claims directly to them if you are under Original Medicare through the RRB.

How to Contact Palmetto GBA for RRB Original Medicare Beneficaries

If you need to submit a claim for a Part B service or ask a question, you can contact Palmetto GBA here:

Palmetto GBA
Railroad Medicare Part B Office
P.O. Box 10066
Augusta, GA 30999-0001

Toll Free: 1-800-833-4455
TTY/TDD: 1-877-566-3572
Website: www.palmettogba.com/medicare
According to the RRB website, you will click on “RRB Specialty MAC Beneficiaries” on the website above

More Information

For more information about Railroad Medicare Benefits, you can visit their website here.

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