A Health Maintenance Organization (HMO) plan is a kind of Medicare Advantage Plan that typically provides health care coverage from specialists, doctors, or hospitals in the plan’s network, except in an emergency situation.
Medicare HMOs are a popular managed-care choice because they offer lower premiums. The premium could be $0 in some plans. But, you have to still be enrolled in (and paying for) Medicare Part B.
Our Medicare experts are here to educate you on all the Medicare Advantage plans so you can decide which one fits you best.
How Do Medicare HMO Plans Work?
First, the insurance carrier contracts with certain doctors in your local area to establish a network. Next, you’ll choose a primary care physician (PCP) who will regulate your care.
If your PCP cannot treat a health condition, he or she will distribute a referral for you to visit a specialist network. A referral may not be required for some services, such as mammograms and preventive care.
As mentioned above, you must first be enrolled in both Medicare Part A and Part B before you can enroll in a HMO plan. You also have to live in the plan’s service area. When you enroll in a Medicare HMO, you consent to receive your care only through the plan’s network, excluding emergencies.
If a Medicare HMO seems too restrictive to you, consider a Medicare PPO plan, which is more flexible.
Common Features of Medicare HMO Plans
- Medicare HMO applications only have one health question. Anybody can enroll during the proper election periods assuming you don’t have End-Stage Renal Failure.
- Premiums could be lower than Medigap plans in your area. In some areas, some plans might even have a $0 premium. But premiums may change from year to year. Go over your Annual Notice of Change letter each fall so you know what to expect.
- You must seek your care from a local network of healthcare providers and hospitals (except in emergencies). Many plans will have you select a primary care physician. When it’s needed, this doctor can regulate a referral to send you to a specialist.
- Many HMO plans include Medicare Part D drug plans. Always check the plan’s drug formulary to confirm that your medications are included in the plan.
- You pay as you go in the order of copays or coinsurance. Each plan features a summary of benefits that will explain how much the provider can charge for specific services. Copays for services (doctor’s visits, lab-work, etc.) will vary.
- Annual Changes – The benefits formulary, provider network, pharmacy network, premium and/or copayments can change on January 1 of each year. Make sure you review plan changes from year to year to decide whether you have to make changes to your coverage.
Medicare HMOs are typically the most limiting type of Medicare Advantage plan. There aren’t any out-of-network benefits unless it’s an emergency. All Medicare Advantage plans have certain restrictions by which you must accept. You can learn more about these rules on our Medicare Advantage page.
Finally, Medicare HMO plan availability differs by county and state. Cornerstone Senior Advisors can verify plan availability in your county.
Contact Us to Learn More About Medicare HMO Plans
Evaluating each HMO plan one-by-one can be exhausting. At Cornerstone Senior Advisors, we specialize in Medicare products. Whether it’s providing information about the network’s service area or thumbing through the plan’s history in the marketplace, we don’t cut corners.
Our agents can also help you weigh factors that are unique to you. For instance, we’ll examine whether the HMO plan has an inherent Part D drug formulary that contains your medications. We want to be your Medicare agent, so call (316) 260-3331 to see how we can help!