“Our members are
what we’re here for.

MENASHA, WI (June 15, 2016) 

Health insurance is complicated, and in today’s world it can be confusing and overwhelming to find the best plan to suit your needs. This is especially true for those of us entering retirement age.

As we leave our employer-sponsored health plans and have to choose our own health insurance, perhaps for the first time in our lives, we’re bombarded with terms like ‘cost sharing’, ‘coverage gap’ and ‘disenrollment’. It is difficult to sort through the information we need to know to select the best plan for our individual needs. You can gain a better understanding of your health insurance needs by beginning to learn about the basics now, before you need to choose a plan.

The two most popular types of health insurance plans are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). Both plan types offer coverage for health care services, but do so in very different ways.

An HMO plan is based on your relationship with a Primary Care Provider, often your family physician. Your Primary Care Provider works with your health insurance company to coordinate your care, creating a treatment plan and offering referrals to specialists when you need one. Most HMO plans only allow you to see a specialist with a written referral from your Primary Care Provider, and require you to see in-network physicians except in the case of medical emergencies. If you have an HMO plan and see an out-of-network provider, you will likely be responsible for the full cost of the visit and treatment.

PPO plans offer more flexibility to make your own health care choices. Under a PPO plan, you are not required to have a Primary Care Provider. Instead, PPO plans are designed to give you the tools to direct your own health care, choose your own physicians and visit specialists of your choice without requiring a referral. PPO plans encourage you to see physicians that are in-network, but also offer a high amount of coverage for out-of-network providers. With a PPO plan, you are able to see out-of-network providers, often times, at just a slightly higher copayment. At Network Health, our Medicare Advantage plans are PPO plans. We structure our coverage this way because the freedom to drive your own health care is particularly important in retirement as you explore your new lifestyle and face new health care challenges.

Under our PPO Medicare Advantage plans, you can see any physician, both in-network and out-of-network, that accepts Medicare beneficiaries. Providers that accept Medicare beneficiaries are accessible to all Network Health Medicare Advantage PPO members. Always ask your physician if they accept Medicare beneficiaries before beginning treatment to ensure the fullest coverage possible.

With a PPO Medicare Advantage plan, you are able to see any provider that accepts Medicare beneficiaries, although you may pay a slightly higher copayment if that provider is out-of-network. This helps to ensure that no matter who you chose to see for your health care, your care and treatment can continue uninterrupted as you enter new stages of your life.

Knowing the basics of health insurance now will help you make better-informed choices about your health insurance down the line. Think about what kinds of coverage and options are important to you, and what type of health insurance plan will best accommodate your needs. You have many options, so take control of your health care coverage and find the plan type that best fits your retirement lifestyle.

Visit NetworkHealthMedicare.com or call us at 800-983-7587 to learn more about Network Health Medicare Advantage plans.


Mary Davis, MD
Chief Medical Officer, Network Health

Mary Davis, MD, is the Chief Medical Officer at Network Health. She is a health insurance industry expert in managing high-quality Medicare programs and promoting value-based care through collaborative health plan and provider programs.