Medicare HMOs vs. PPOs

by | Oct 2, 2025 | Medicare Advantage

Which Plan is Right for You?

Choosing between a Medicare HMO (Health Maintenance Organization) and a Medicare PPO (Preferred Provider Organization) has always been about balancing cost with flexibility. But in today’s Medicare Advantage marketplace, the differences are becoming even more important. With Medicare plan changes in 2025 and shifting carrier strategies, it’s crucial to understand not only how these plans work but also how the landscape is evolving.

As your trusted Medicare resource, Emerald Medicare is here to break down what these plans really mean for you and why reviewing your options carefully each year matters more than ever.

The Basics: Medicare Provider Networks Explained

A provider network is simply the list of doctors, hospitals, and other healthcare providers that contract with a Medicare Advantage (MAPD) plan. These providers agree to accept the plan’s payment terms, which helps the plan effectively manage their costs. That’s why staying in-network almost always results in lower out-of-pocket expenses.

  • Medicare HMO Plans: Require you to use in-network providers for coverage (except emergencies). You typically need to choose a primary care provider (PCP) who coordinates your care and provides referrals for specialists. Costs are often lower, and some Medicare Advantage HMOs even offer $0 premiums.
  • Medicare PPO Plans: Allow you to see both in-network and out-of-network providers. You don’t need referrals for specialists, but premiums and deductibles are generally higher. Out-of-network visits can mean significantly higher costs.

Why Medicare PPOs Are Declining and HMOs Are Expanding

In recent years, many carriers have started phasing out or scaling back Medicare Advantage PPO options. The reason is simple: PPOs are more expensive for insurance companies to maintain, and those costs are increasingly difficult to manage. By contrast, Medicare HMOs allow insurers to better control costs because care is funneled through networks and coordinated by primary care providers. This model has become more profitable and more sustainable for insurers — and as a result, HMOs are growing in availability.

For beneficiaries, this means you’ll likely see more HMO Medicare Advantage plans in 2025, while PPOs may become less common or come with higher premiums to reflect the added flexibility.

The Impact of the Inflation Reduction Act on Medicare Plans

Starting in 2025, the Inflation Reduction Act introduces a $2,000 annual cap on out-of-pocket prescription drug costs. This change applies across Medicare Advantage plans, including both HMOs and PPOs. It’s a huge win for consumers, helping protect retirees from unpredictable, sky-high pharmacy bills.

The law also allows Medicare to negotiate prices for certain high-cost drugs, which may help reduce overall costs in the system. This could benefit enrollees across both HMO and PPO plan types, though the exact impact will vary by medication and carrier.

Hidden Medicare Plan Changes to Watch For

Beyond these big themes, there are subtle changes that consumers often overlook. Carriers aren’t just restructuring plans; some are also reducing broker compensation or shifting benefits in ways that may not be obvious.

For example, one Medicare Advantage plan in 2025 may advertise new perks like food cards or fitness memberships, while at the same time quietly reducing dental, vision, or over-the-counter allowances. These trade-offs don’t always get highlighted in marketing materials, which is why reviewing the Annual Notice of Change every fall is so important.

Choosing the Right Medicare Advantage Plan for 2026 & Beyond

When deciding between a Medicare HMO vs. PPO, ask yourself:

  • Do I want to keep my current doctors and specialists? Are they in-network on an HMO?
  • Am I comfortable coordinating my care through a primary care provider and getting referrals?
  • Would I rather pay a little more each month for the freedom to see providers outside the network?
  • How much do I rely on extra benefits like dental, vision, or over-the-counter allowances?

There’s no one-size-fits-all answer. The right plan is the one that best aligns with your health needs, financial priorities, and comfort level with provider restrictions.

Stay Ahead of Medicare Plan Changes With Emerald Medicare

At Emerald Medicare, our role is to help you see past the fine print, understand how these changes affect you personally, and ensure you’re in the plan that delivers the best value. Don’t assume your plan will look the same just because it has in the past. Even plans with the same name can change dramatically from year to year.

Click below to schedule an appointment with one of our Medicare Experts.

Or, Contact Us
📞 (888) 683-6372 or (845) 358-1220
📧 office@emeraldmedicare.com

Mark Brownstein, CSA® | Calendly

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Why do Medicare benefits change each year?

by | Sep 23, 2025 | Industry Shifts & Updates, Medicare Benefits

If you’ve been on Medicare for more than a year, you’ve likely noticed that something always changes—whether it’s your plan premium, your drug coverage, or which doctors are in-network. Many people ask us: “Why doesn’t Medicare just stay the same?”

The truth is, while Original Medicare (Parts A and B) stays relatively stable, Part D drug plans and Medicare Advantage plans are offered by private insurers—and they’re allowed (and expected) to make changes annually. Here’s why those changes happen—and more importantly, what you can do to stay ahead of them.

Plans Adjustments Based on Federal Funding & Regulations

Each year, the Centers for Medicare & Medicaid Services (CMS) announces changes to payment structures, coverage rules, and plan requirements. These updates are often tied to:

  • Inflation and rising healthcare costs
  • New laws like the Inflation Reduction Act
  • Changes in how much Medicare reimburses insurers

📌 In 2026, for example, a major prescription drug cost overhaul is taking effect—impacting how plans structure their formularies and copays.

Drug formularies are reviewed and modified each year

If you have a Part D or Medicare Advantage plan with drug coverage, your insurer re-evaluates which medications they cover, how much they cost, and which pharmacies are preferred.

That’s why your plan may cover your medication one year and drop it or raise the cost the next.

💡 This is one of the top reasons we encourage clients to review their coverage every October—even if nothing else has changed.

Premiums, Copays, and Deductibles change alongside market conditions

Insurance companies adjust plan premiums, deductibles, and copay amounts based on:

  • Medical trends
  • Prescription drug pricing
  • Provider contracts
  • Member usage

While these changes are often modest, some plans may increase costs significantly—or reduce benefits to keep premiums low.

⚠️ That “great plan” you had last year may no longer be the best value for you today.

Plans can be discontinued or renamed

Some plans are removed from the market entirely. Others are renamed or merged with similar options.

In 2026, for example, several major carriers are terminating certain Advantage plans, impacting hundreds of thousands of beneficiaries nationwide.

🏥 If your plan is discontinued, you’ll get a Special Enrollment Period—but waiting too long to act could lead to coverage gaps.

✅ What You Can Do: Review and Reassess Annually

The Annual Enrollment Period (October 15 – December 7) exists for this exact reason: to give you the opportunity to switch plans, compare drug coverage, and adjust your Medicare strategy for the year ahead.

At Emerald Medicare, we provide:

  • Coverage reviews every fall
  • Access to smart tools like RxCare for real-time drug plan savings
  • Help comparing Part D, Medigap, and Medicare Advantage options
  • Unbiased advice from licensed brokers (never pushy sales tactics)

Be Proactive, Not Reactive

The only constant in Medicare is change—but that’s not a bad thing. With a trusted partner on your side, these annual adjustments become opportunities to improve your coverage, reduce your costs, and feel more confident in your choices.

Let us help you prepare for 2026 and beyond.

Click below to schedule an appointment with one of our Medicare Experts.

Or, Contact Us
📞 (888) 683-6372 or (845) 358-1220
📧 office@emeraldmedicare.com

Mark Brownstein, CSA® | Calendly

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Do I Need Medicare Part A and/or Part B If I Am Still Working?

by | Sep 18, 2025 | Original Medicare, Rules & Enrollment

Of course, turning 65 doesn’t mean you have to retire—but it does mean Medicare eligibility begins, and many people still wonder:

“If I’m still working and have health insurance through my employer, do I need to enroll in Medicare when I turn 65?”

The answer depends on several factors—including your employer size, your current health coverage, and whether you’ve already started Social Security. At Emerald Medicare, we help clients evaluate these decisions every day to avoid penalties, gaps, or unnecessary costs.

Let’s break it down…

✅ Start with Medicare Part A: Most People Enroll

Medicare Part A (hospital insurance) is premium-free for most people and generally covers inpatient hospital stays, skilled nursing, and hospice care.

  • If your employer has coverage and you’re still working, you can usually enroll in Part A at 65 without any downside.
  • HOWEVER—if you’re contributing to a Health Savings Account (HSA), you may want to delay Part A to avoid tax issues.

🧾 What About Part B? It Depends on Employer Size

Medicare Part B covers outpatient care, doctor visits, and preventive services. Unlike Part A, you do pay a monthly premium for Part B—so enrolling unnecessarily could cost you.

IF YOUR EMPLOYER HAS 20 OR MORE EMPLOYEES:

  • You can delay enrolling in Part B without penalty.
  • Your employer coverage remains primary, and Medicare is secondary.
  • You’ll qualify for a Special Enrollment Period (SEP) when you retire or lose coverage—no late penalty.

IF YOUR EMPLOYER HAS FEWER THAN 20 EMPLOYEES:

  • You must enroll in Medicare Part A and B when first eligible.
  • In this case, Medicare becomes your primary insurance, and your employer plan pays second—or not at all.
  • Failing to enroll could leave you uninsured and/or penalized.

Always check with your HR department—don’t assume your employer coverage counts as “creditable” for Medicare.

💼 Still Working with an HSA? Be Careful

If you’re contributing to a Health Savings Account (HSA) and you enroll in any part of Medicare, including Part A, you must stop HSA contributions.

  • Enrollment in Medicare (even Part A) disqualifies you from contributing.
  • Retroactive Part A enrollment (up to 6 months) can create IRS penalties if you’re not careful.
  • We typically recommend stopping HSA contributions at least 6 months before you apply for Medicare.

📍 Why It Matters

Making the wrong choice about when to enroll can lead to:

  • Late enrollment penalties
  • Gaps in coverage
  • Unexpected bills if Medicare should have paid primary
  • Tax consequences for HSA users

✅ When to Enroll (or Delay) Original Medicare: A Quick Recap

Situation Part A Part B
Employer has 20+ employees, no HSA Usually enroll Delay OK
Employer has fewer than 20 employees Enroll Enroll
Still working and using an HSA Delay Delay
Retiring soon or leaving coverage Enroll Enroll (within 8 months of losing coverage)

Click below to schedule an appointment with one of our Medicare Experts.

Or, Contact Us
📞 (888) 683-6372 or (845) 358-1220
📧 office@emeraldmedicare.com

Mark Brownstein, CSA® | Calendly

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High Deductible Medicare Supplement Plan G (HD-G): A Quick Guide

by | Sep 11, 2025 | Medicare Supplement

Why the High Deductible Medicare Supplement Plan G Could Be the Right Choice

Choosing the right Medicare Supplement plan can feel overwhelming. With so many options, it’s important to find a balance between affordable monthly costs and reliable coverage when you need it most. While the standard Medicare Supplement Plan G continues to be one of the most popular options, there’s another version that’s gaining attention: the High Deductible Plan G (HD-G).

At Emerald Medicare, our licensed experts help clients every day understand the differences between these plans so you can make the choice that fits both your health and your budget. Here’s what makes the High Deductible Plan G worth considering.

Lower Monthly Premiums

One of the biggest advantages of the High Deductible Plan G is the significantly lower monthly premium compared to standard Plan G. This means you pay less each month for your coverage, which can free up more money for other retirement expenses. For Medicare beneficiaries on a fixed income, that savings can make a real difference.

Comprehensive Benefits After the Deductible

In 2025, the annual deductible for the High Deductible G is $2,800. Once that deductible is met, the plan covers 100% of the same benefits as a traditional Plan G. That includes:

  • Medicare Part A coinsurance and hospital costs
  • Medicare Part B coinsurance or copayments
  • Skilled nursing facility coinsurance
  • Part A hospice care coinsurance or copayments
  • The Medicare Part A deductible
  • Medicare Part B excess charges
  • Coverage for foreign travel emergencies (80%, up to plan limits)

Essentially, after you meet the deductible, you enjoy the same comprehensive coverage and peace of mind that has made Plan G so popular.

A Smart Option for Healthy Individuals

High Deductible Plan G can be especially appealing if you’re generally healthy and don’t anticipate frequent doctor visits or hospital stays. You’ll save money on your monthly premiums, and while you may have to pay more out of pocket if an unexpected medical event occurs, your maximum yearly costs are capped at the deductible plus your premiums. This balance of affordability and protection makes HD-G an attractive choice for many Medicare recipients.

Nationwide Access and Flexibility

Just like a standard Plan G, the High Deductible G allows you to see any doctor or hospital in the U.S. that accepts Medicare. There are no networks and no referrals required. That flexibility ensures you can access the care you need, whether you’re close to home or traveling.

Predictable Costs with Peace of Mind

One of the challenges with Medicare alone is the potential for unpredictable out-of-pocket expenses. With the High Deductible Plan G, you know exactly what your worst-case scenario costs could be each year: the deductible amount plus your monthly premiums. This predictability gives you financial confidence and helps with budgeting in retirement.

Is High Deductible Plan G Right for You?

The High Deductible Plan G isn’t the perfect fit for everyone, but for many Medicare recipients, it strikes the right balance of lower monthly premiums and solid financial protection. If you’re healthy, budget-conscious, and want predictable maximum costs, HD-G may be the right choice for your Medicare coverage.

At Emerald Medicare, we specialize in helping you evaluate your options and choose the plan that works best for your unique needs. Our services are always 100% free, and our team is dedicated to making Medicare simple, clear, and stress-free.

Making the right Medicare decision doesn’t have to be confusing. If you’d like to learn more about whether High Deductible Plan G is a good fit for you, we’re here to help.

Click below to schedule an appointment with one of our Medicare Experts.

Or, Contact Us
📞 (888) 683-6372 or (845) 358-1220
📧 office@emeraldmedicare.com

Mark Brownstein, CSA® | Calendly

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Building Value Through Professional Partnerships

by | Sep 2, 2025 | General

How Emerald Medicare Enhances Collaboration through Allied Professionals

At Emerald Medicare, we take pride in building strong partnerships with a wide range of professionals, including Financial Planners, CPAs, and Health Professionals. Our goal is to provide expert Medicare guidance that complements the services these professionals offer, enhancing the value they bring to their clients. Further, these partnerships ensure we’re prepared when our clients need assistance with something besides Medicare; we can confidently connect them with the proper medical and/or financial professional for their needs. By offering education, resources, and hands-on support, we empower firms and medical offices to confidently address the Medicare needs of their clients and patients. Here’s how we work with these allied professionals to deliver outstanding results.

Partnering with Financial Planners & Wealth Advisors

Financial Planners and Wealth Advisors play a critical role in helping clients achieve long-term financial security. Integrating Medicare planning into Wealth Planning services adds immense value and builds client trust. At Emerald Medicare, we collaborate with planners & firms across the country to offer free expert Medicare consultations that complement their financial advice.

 

How We Support Financial Planners:

  • Customized Medicare Education: We provide tailored Medicare education that aligns with the client’s financial goals, helping them understand their options for Medicare Parts A, B, C, and D as well as Medigap plans.
  • Annual Coverage Reviews: Our team conducts annual reviews to ensure that clients’ Medicare coverage adapts to changes in their healthcare needs and financial circumstances.
  • Hands-On Guidance: Planners can connect us directly with their clients or work with us on behalf of their clients. Either way, we guide each individual through the Medicare enrollment process, ensuring they choose the best plan for their unique situation.
  • Unbiased Recommendations: As an independent brokerage, we’re not tied to any specific insurance provider. Our recommendations are based solely on what’s best for the client, offering planners peace of mind.

This collaborative approach not only enhances the value planners provide to their clients but also strengthens client loyalty and satisfaction.

Partnering with CPAs and Tax Professionals

CPAs and Tax Professionals often encounter clients who are approaching Medicare eligibility or are already Medicare beneficiaries. Understanding Medicare’s financial implications, such as premiums, penalties, and tax considerations, is crucial for their clients’ financial well-being. At Emerald Medicare, we partner with CPA firms, large and small, to provide expert Medicare insights that complement their tax and financial services.

 

How We Support CPAs:

  • Presentations and Educational Events: We sponsor professional organizations such as state chapters of the Society of Public Accountants (MassCPA, CTCPA, NYCPA, etc.) and the Financial Planning Association (FPA). Through these partnerships, we deliver seminars, webinars, and Lunch & Learn sessions tailored to CPAs and their firms.
  • Medicare Guidance for Clients: CPAs can refer their clients to us for one-on-one Medicare consultations. We provide personalized advice that helps clients make informed decisions about their healthcare coverage.
  • Streamlining Complexities: We help CPAs understand how Medicare interacts with tax planning, such as the tax-deductibility of premiums and penalties for late enrollment. This knowledge enables CPAs to provide more comprehensive financial advice.
  • No-Cost Expertise: Our services are always free, allowing CPAs to enhance their value proposition without adding costs for their clients.

By integrating Medicare education and resources into their practice, CPAs can offer a more holistic service to their clients while benefiting from the expertise of Emerald Medicare.

Partnering with Health Professionals & Senior Advisors

Health professionals—including doctors, case managers, social workers, and Certified Senior Advisors (CSAs)—are often the first to hear their patients’ or clients’ concerns about Medicare. These professionals play a crucial role in guiding older adults through their healthcare and retirement journey, and Emerald Medicare partners with them to ensure their patients and clients receive the best possible Medicare guidance.

 

How We Support Health Pros and Senior Advisors:

  • Collaboration with Medical Offices: We partner with local medical practices to provide Medicare education and resources that help their staff address patient questions confidently.
  • Support for Case Managers and Social Workers: Through partnerships with organizations like the Case Management Society of America (CMSA), we offer training sessions and resources tailored to case managers and social workers. This support enables them to guide patients toward informed Medicare decisions.
  • Partnerships with Certified Senior Advisors (CSA): As active members and presenters at the Society of Certified Senior Advisors’ national conference, we regularly collaborate with CSAs who guide older adults through complex retirement and aging decisions. By partnering with Emerald Medicare, CSAs gain an experienced ally who can address the Medicare-specific concerns of their clients, ensuring comprehensive support.
  • Patient and Client Referrals: Health professionals and senior advisors can refer their patients or clients directly to Emerald Medicare for personalized consultations. We assist each individual in finding plans that meet their medical and financial needs, ensuring a smooth enrollment process.
  • Professional Events: By sponsoring and attending events hosted by medical and senior-focused organizations, we build strong professional relationships and provide tools that help allied professionals address Medicare inquiries effectively.

Our collaboration with health professionals, case managers, and senior advisors enhances both patient and client satisfaction while allowing professionals to focus on their core services.

You Can Partner with Emerald Medicare

At Emerald Medicare, we believe in the power of collaboration to deliver better outcomes for clients and patients. Whether you’re a Financial Planner, CPA, Health Professional, or Certified Senior Advisor, our expert team is here to support your efforts by providing education, resources, and hands-on guidance tailored to your clients’ and patients’ unique needs. Best of all, our services are always 100% free, making it easy to enhance your value without adding costs.

If you’re interested in partnering with Emerald Medicare, contact us today to learn more about how we can work together. Schedule an appointment with one of our expert brokers through Calendly, or reach out directly using the information below.

Click below to schedule an appointment with one of our Medicare Experts.

Mark Brownstein, CSA® | Calendly

Contact Us
📞 (888) 683-6372 or (845) 358-1220
📧 office@emeraldmedicare.com

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