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Medicare Advantage HMO Plans

October 6,2016

What is an HMO Plan?

The acronym “HMO” means “Health Maintenance Organization.” A Medicare Advantage plan that provides its benefits through an HMO uses a network of providers to deliver the plan’s health care services to people enrolled in the plan. Like all Medicare Advantage plans, Medicare Advantage HMO plans offer all medical benefits and hospital benefits covered under Medicare Part A and Part B, with the exception of hospice care, and the majority of these HMO plans come with prescription drug coverage.

Getting Care with a Medicare Advantage HMO Plan

As a member of an HMO, you will be required to choose a primary care physician (“PCP”) within the network who will provide most of your health care. In most cases, you would need to get a referral in order to see a specialist. Certain services, including yearly mammogram screenings, usually do not require a referral.

Health care services obtained from any doctor, health-care provider or at any hospital outside of the HMO network are typically not covered, with the exception of an emergency or out-of-area urgent care and dialysis. If you decide to get health care outside of the plan’s network, keep in mind that you may have to pay the full cost for the services received. Additionally, HMO plans may have coverage rules, such as getting prior approval for specific services, which enrollees must adhere to in order to get coverage for eligible services.

There are HMO plans that may allow you to visit out-of-network health care providers for certain services, typically for a higher cost. This type of plan is also known as an HMO plan with a point-of-service (POS) option.

Finding an HMO Plan in Your Area

Medicare Advantage HMO plans are offered by several private insurance companies across the nation. The availability of HMO plans from various carriers will depend on the county and state in which you live. Additionally, the following factors for HMO plans will vary between plans, depending on the insurance carrier that is offering the plan:

  • Approved network of health-care professionals and facilities
  • Costs (deductibles, copayments, coinsurance, and other out-of-pocket expenses)
  • Coverage rules (prior authorization)
  • Prescription drug coverage
  • Additional health and medical benefits

Questions to Ask Before Joining an HMO Plan

Out of all the Medicare Advantage plan types, HMO plans frequently have lower deductibles, coinsurance, and copayments; however, this may not be the best plan for everyone’s health needs and budget. Since an HMO requires you to use health care providers within its network, alongside your evaluation of plan coverage, you should also ask the following questions before enrolling in an HMO:

  • Is my current doctor within theHMO’s network of health care providers?
  • Are the health care facilities belonging to the HMO network located near me?
  • Are there any customer satisfaction surveys for the HMO I can review?