Insurance and Billing | TriValley Medical Group (2024)

A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare (a government plan) to provide you with all your benefits (Part A and in most cases, Part B). Medicare Advantage Plans include Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and are not paid for by Medicare.

Medicare Advantage plans are designed to manage the costs of medical care, which means members enjoy lower out-of-pocket expenses compared to other types medical insurance. Visits to the doctor’s office, hospital charges and many other medical care expenses are often covered at 100% after a small copayment. Generally, preventive care, prescription drugs, routine physicals, lab tests, vision exams are covered. Medicare Advantage plans do not typically require you to pay an annual deductible before services are covered and usually have no lifetime maximums.

HMO stands for Health Maintenance Organization. With an HMO plan, you must choose a Primary Care Physician (PCP) from a network of local healthcare providers who will refer you to in-network specialists or hospitals when necessary.When you apply for an HMO plan, you’ll select a Primary Care Physician who will be the first point of contact for your healthcare. You are encouraged to build a strong relationship with your PCP because they will connect you to specialists or other health care providers. Your PCP will be able to see the total picture of your overall health and understand your needs. Together you can make the best decisions to manage your health and well-being, which includes your PCP making referrals to specialists if needed.

With an HMO plan, your out-of-pocket medical costs and monthly premiums will generally be lower than with other types of plans. If you are someone who doesn’t see a lot of specialists or would like having your care coordinated through a PCP, then you might save more money with an HMO plan.

PPO plans, or “Preferred Provider Organization” plans, are also popular types of plans in the Individual and Family market. PPO plans allow you to visit whatever in-network physician or healthcare provider you wish without first requiring a referral from a primary care physician.

As a member of a PPO plan, you’ll be encouraged to use the insurance company’s network of preferred doctors and you usually won’t need to choose a primary care physician. No matter which healthcare provider you choose, in-network healthcare services will be covered at a higher benefit level than out-of-network services. It’s important to check if you provider accepts your health plan so you receive the highest level of benefit coverage.

You will probably have an annual deductible to pay before the insurance company starts covering your medical bills. You may also have a an additional co-payment of about for certain services or be required to cover a certain percentage of the total charges for your medical bills.

You may get a written notice called an “Advance Beneficiary Notice of Non-coverage” (ABN) from your doctor, other healthcare provider or supplier if both of these apply:

• You have Traditional Medicare
• Your doctor, other health care provider, or supplier thinks Medicare probably (or certainly) won’t pay for the items or services you got.

However, an ABN isn’t required foritems or services that Medicare never covers.

The ABN lists:

• The items or services that Medicare isn’t expected to pay for
• An estimate of the costs for the items and services
• The reasons why Medicare may not pay

The ABN gives you information to make an informed choice about whether or not to get items or services, understanding that you may have to accept responsibility for payment.

You’ll be asked to choose an option box and sign the notice to say that you read and understood it. You must choose one of these options:

• Option 1: You want the items or services that may not be paid for by Medicare. Your provider or supplier may ask you to pay for them now, but you also want them to submit a claim to Medicare for the items or services. If Medicare denies payment, you’re responsible for paying, but, since a claim was submitted, you canappealto Medicare.
• Option 2: You want the items or services that may not be paid for by Medicare, but you don’t want your provider or supplier to bill Medicare. You may be asked to pay for the items or services now, but because you request your provider or supplier to not submit a claim to Medicare, you can’t file an appeal.
• Option 3: You don’t want the items or services that may not be paid for by Medicare, and you aren’t responsible for any payments. A claim isn’t submitted to Medicare, and you can’t file an appeal.

An ABN isn’t an official denial of coverage by Medicare. You have the right to file an appeal if payment is denied when a claim is submitted.