A HMO, or Health Maintenance Organization, is a type of Medicare Advantage (MA or Part C) plan. HMO plans always offer the same benefits as any other Medicare plan, but they are also able to provide additional benefits, many plans include vision, dental, and hearing coverage.
HMO plans are different from other Medicare Advantage plans because they require a strict network and you will usually need to select and stick with one primary care doctor.
Pros and Cons of Medicare HMO Plan Networks
The HMO option is certainly not for everyone. Having a strict network means that you will turn to the same doctor for most of your healthcare needs.
Some plans are called “HMO POS,” or HMO Point-of-Service plans. These allow you to see providers outside of your network for certain services. If you need to use that benefit, you will usually have to get approval from your plan first, and your provider needs to recommend the other provider.
For example, if your primary care physician (PCP) suggests that you need to see a nutritionist or other specialist, your PCP can refer you to a nutritionist that he or she trusts and send a request for coverage to your HMO. The “con” to the HMO option is that your plan can deny your out-of-network coverage.
The “pro” to selecting one primary physician and having a Health Maintenance Organization is that all of your care is grouped together and managed in one place. Your providers usually work together to manage your care, preventing unnecessary costs.
A licensed agent with Medicare Plan Finder can help you determine if a HMO is right for you. Our agents can help you find the right plan based on your budget and lifestyle needs. To learn more, call 833-438-3676 or contact us here.
Medicare HMO vs. PPO
Where an HMO requires a very specific network, a PPO, or Preferred Provider Organization, can cover services outside of your network. With a PPO plan, you’ll be able to see any provider without needing a referral from your primary physician.
Granted, the added flexibility of a PPO plan comes with a higher premium than an HMO plan. If costs are your primary concern, HMOs are the way to go – but if you can afford the flexibility, a PPO may be for you.
If you have questions about HMOs vs. PPOs, your agent can answer all of them and help you make the right choice for you.
What is Medicare Advantage?
Medicare HMO plans and other types of Medicare Advantage plans are great options for people who want more coverage than what Original Medicare provides.
Original Medicare is what everyone who has Medicare will have, but its coverage is limited. Medicare Advantage plans can add anything from extra medical coverage to additional benefits like home healthcare, telemedicine, and full dental coverage.
Many MA plans can offer coverage for whole health benefits. Along with additional medical and dental benefits, MA plans can offer coverage for meal delivery, non-emergency medical transportation and even fitness classes!
Your agent can discuss the differences between other types of Medicare plans like Medicare Supplements and Medicare Advantage plans.
HMO Eligibility and Costs
Most people who are eligible for Medicare are eligible for HMO plans. The only exceptions are that not every county has HMO plans available, and most HMO plans do not accept Medicare beneficiaries with ESRD (End-Stage Renal Disease).
Just like your Original Medicare coverage, you will receive a card in the mail when you enroll in a HMO plan. When you visit a doctor or hospital, use your HMO card instead of your Medicare card to get the most coverage.
Every Medicare Advantage plan is different, but you will generally be responsible for paying certain costs.
All HMO plans come with a premium you will owe every month, but some are as low as $0.
You’ll also be responsible for paying copays such as $10 or $20 when you see a doctor and you may have to pay a deductible before your coverage starts.
CMS Star Ratings for Medicare Advantage HMO Plans
Medicare Advantage plans are rated based on the following criteria:
- How easy it is to access preventive services (such as annual physical exams and health screenings)
- Care coordination between providers
- How often plan members receive treatment for chronic conditions
- Member satisfaction
- Plan performance from year to year
- Customer service quality
Five-star HMO plans may be available in your area. Talk to your agent to learn more.
Medicare Advantage HMOs Near You
Medicare Advantage HMO plans are not available in every zip code. However, we have highly-trained, licensed agents in 38 states who can help you discover the options available in your neighborhood. To get started, send us a message or give us a call at 833-438-3676.
This post was originally published on February 26, 2019, by Anastasia Iliou and was updated on August 12, 2019, by Troy Frink.