Humana Medicare Advantage PFFS vs. HMO

In this article...
  • Humana offers several types of Medicare Advantage plans, including HMO plans and PFFS Medicare plans. Learn more about Humana PFFS vs. HMO plans, including what they cover, how much they cost, what doctors accept them and how you can enroll.

When shopping for a Humana Medicare Advantage plan, you may have a choice of a few different types of policies you can enroll in, depending on where you live. Two popular choices among Humana Medicare beneficiaries are HMO plans and PFFS plans, which we will compare below to help you make the best decision for your needs. 

What Is a Humana HMO?

HMO stands for “Health Maintenance Organization.” 

Members of a Humana HMO plan choose a primary care physician from within the Humana network of providers. This general doctor serves as a gatekeeper for your care and coordinates services with providers from within the plan’s network whenever further tests or treatment are needed.

HMO plans are a form of managed care that take a more “team approach” to each member and emphasize preventive care. You will generally need a referral from your primary care physician in order to make appointments with specialists and other doctors. 

What Is a Humana PFFS?

PFFS stands for “Private Fee-For-Service.”

Medicare PFFS plans don’t have a network of participating providers in the same way that an HMO plan does. Rather, a Humana PFFS plan contracts with any and all Medicare-participating providers who agree to the Humana plan’s payment terms.

A PFFS plan may be accepted on a patient-by-patient or even service-by-service basis. So a provider may accept your PFFS plan for one particular service but not another. PFFS plan members do not typically have to use a primary care physician, and there is no need to obtain a referral to see a specialist. 

The Differences Between Humana HMO and PFFS Plans

There are a number of differences between a Humana HMO plan and a Humana PFFS plan. 

Coverage

Medicare HMO plans and Medicare PFFS plans provide all of the same coverage found in Medicare Part A and Part B. Both types of plans also have the freedom to offer additional benefits not found in Original Medicare, such as routine dental, hearing and vision care.

Most Medicare Advantage plans – both HMOs and PFFS plans – offer Medicare prescription drug coverage.

Premiums

Monthly premiums for HMO plans tend to be lower than the monthly premiums for other types of Medicare Advantage plans. Many of the $0 premium plans that may be available where you live are likely HMOs.

Deductibles and Cost Sharing

Humana HMO and PFFS plans are often similar in their pricing structures. Plans may or may not feature deductibles, while copayments and coinsurance will typically vary according to the type of service. Deductibles, copayments and coinsurance are often a little lower in HMOs. 

One difference between these plans as it relates to cost measures is that PFFS plans can practice balance billing, which means providers can charge up to 15% more than the Medicare-approved amount and pass the difference onto the consumer. In Original Medicare, this is known as an “excess charge.” There is no balance billing with HMO plans, as providers are restricted to charging the Medicare-approved amount. 

Provider Choice

With an HMO plan, your choice of health care providers will be restricted to those within the Humana network. When emergency care is needed, however, HMO members may see any provider in the U.S. 

PFFS plans allow you to see any health care provider who accepts Medicare. However, the doctor or provider must also agree to the payment conditions of the Humana plan. A provider may agree to accept your PFFS plan for one particular service but not another. 

Referrals

HMO plan members will lean on the guidance of their primary care doctor and in most cases will not be able to visit a specialist without a referral from this physician. 

There is typically no need to obtain a referral in order to make an appointment with a specialist when you have a PFFS plan. 

Out-of-Pocket Spending Limit

Medicare HMO and Medicare PFFS plans are required to include an annual out-of-pocket limit for beneficiaries. In 2021, that limit is $7,550 for the year. After you spend that amount on covered care, your Medicare plan will pay for the full costs of your covered care for the rest of the year. 

Pros and Cons of HMO and PFFS

There are advantages and disadvantages to both Medicare Advantage HMO plans and PFFS plans. 

Pros and Cons HMO vs. PFFS Medicare Plans
Plan Type Pros Cons
Meicare HMO

- Utilizing a primary care doctor who you can build a rapport with

- Having your care coordinated among a team of providers

- Generally better preventive care coverage

- More affordable premiums and no balance billing

- More limited network of providers

- Requirement to obtain a referral for specialist visits

Medicare PFFS

- Wide open options for health care providers you can see

- No need to obtain a referral to see a specialist

- Typically a little more expensive than HMO plans

- Plan acceptance can be inconsistent, even with the same provider

- Members may be vulnerable to excess charges

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