Medicare PPO and HMO

Goals

To understand the differences between Medicare advantage PPO vs HMO, in terms of average bed days and overall differences in the plans — for both the general US plans and the North Carolina-specific plans.

Early Findings

North Carolina

  • Blue Medicare PPO is the Blue Cross Blue Shield Medicare PPO offered in North Carolina.
  • Blue Medicare HMO is the Blue Cross Blue Shield Medicare HMO offered in North Carolina.

Blue Cross PPO

  • The PPO plan covers in-network, inpatient hospital stays from seven days and beyond with no copay.
  • For skilled nursing facility stays, the PPO offers days 1-21 and days 61-100 with no copay, but days 21–60 require a $172 copay.
  • Under the PPO plan, member liability "may be greater for services received out of network than services received in network." Out-of-network services may be subject to coinsurance, based on the allowed amount rather than the lower contract amount. Also, out-of-network providers are not required to offer care unless it is an emergency situation.

Blue Cross HMO

  • The HMO plan covers inpatient hospital stays from seven days and beyond with no copay.
  • For skilled nursing facility stays, the PPO offers days 1-21 and days 61-100 with no copay, but days 21–60 require a $172 copay.
  • Blue Medicare HMO members are required to use plan providers, except in emergency or urgent care situations, "or for out-of-area renal dialysis." If a member seeks routine care from an out-of-network provider, "neither Original Medicare nor Blue Medicare HMO is responsible for the costs."

Average Bed Days Under Medicare Advantage

  • Two studies, one from 2015 and other from 2018, explore the differences in hospital stays and costs under Medicare Advantage (MA) and Medicare Feed-for-Service (FFS) plans. In both studies, data from 2013 was used, suggesting these may be the most current available figures. However, neither study segments the data for PPOs and HMOs.
  • The 2015 study compares hospital stays under MA and FFS plans, finding that the average length of stay for those under 65 with Medicare Advantage was 5.4 days, while it was 6.1 days for those 65 and older. Similarly, under FFS, the average length of stay for those under 65 was 5.2 days, while it was 5.6 days for those 65 and older.
  • The 2018 study focused on cost and found that the average MA p"rice per discharge across all hospital stays was $10 667 or nearly identical to the average Medicare FFS price for those stays of $10 716."

Summary of Initial Findings Related to Goals

  • During our initial research, we were able to find the plan benefits for both Blue Medicare PPO and Blue Medicare HMO in North Carolina, including some general plan differences and an overview of their coverage for inpatient care. We were unable to find the average bed days under Medicare Advantage for PPO and HMO.

Proposed next steps:

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