Two Medicare Advantage HMO plan examples

*Note- Below are hypothetical examples only of what some benefits may look like in an HMO plan:

Plan ABCPlan XYZ
Medicare Advantage HMO Plans$0/mo.$34/mo.
Office primary care physician copay$0$0
Specialist copay$30$45
Max-out-of-pocket limit per year$4,500$5,500
Hospital Inpatient cost share (Days 1 – 6)$195/day$250/day
Hospital Inpatient cost share (Days 7 – 90)$0/day$0/day
Doctor visits copay$0$0
Specialist visit copay$30$45
Skilled Nursing Facility copay In-Network (Days 1 – 20)$0$0
Skilled Nursing Facility copay In-Network (Days 21 – 100)$178/day$178/day
Outpatient surgery at Outpatient Hospital$195$250
Outpatient surgery at Ambulatory Surgical Center$145$200
Emergency room copay$90$90
Preferred Urgent Care copay$30$30
Non-preferred Urgent Care copay$40$40
Diagnostic mammography$30-$50$45-$50
Lab services copay$0$0
Diagnostic tests and procedures copay$0-$100$0-$50
Outpatient X-rays$0-$100$0-$50
Medicare-covered foot care (podiatry) – copay$30$45
Medicare-covered chiropractic services – copay$20$20
Physical, occupational and speech therapy – copay$30$30
Cardiac rehabilitation – copay$30$30
Pulmonary rehabilitation – copay$30$30
Optional Supplemental Dental Plan with $2000 calendar year max benefit$38/mo.N/A
Routine foot care (up to 12 visits)$0$0
Over-the-counter (OTC) mail order allowance every quarter (3 months)$90$75

The main difference between these two HMO plans is the $34 plan includes greater comprehensive dental coverage including dentures and root canals, where the $0 plan has routine dental, i.e. cleanings, x-rays and exams. *Note: Both plans have additional covered items not detailed in illustration including routine vision and hearing coverage.

Below is an “example only” of how a drug plan may look showing costs
at a Preferred and Standard pharmacy


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