MEDICARE ADVANTAGE HMO PLANS

 

Medicare HMO plans are a popular option in America. According to the Kaiser Family Foundation, approximately 30% of Medicare beneficiaries are enrolled in some type of Medicare Advantage plan.


Medicare HMOs are common because of the lower premiums they often offer. In some plans, that premium may be as low as $0. However you must still be enrolled in and paying for Medicare Part B. You usually must also treat with in-network providers except in the case of an emergency.


 

Health Maintenance Organization (HMO)

In HMO Plans, you generally must get your care and services from providers in the plan's network, except:


  • Emergency care
  • Out-of-area urgent care
  • Out-of-area dialysis

In some plans, you may be able to go out-of-network for certain services. But, it usually costs less if you get your care from a network provider. This is called an HMO with a point-of-service (POS) option.


Are prescription drugs covered in Health Maintenance Organization (HMO) Plans?


In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want Medicare prescription drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage.


Do I need to choose a primary care doctor in Health Maintenance Organization (HMO) Plans?


In most cases, yes, you need to choose a primary care doctor in HMO Plans.


Do I have to get a referral to see a specialist in Health Maintenance Organization (HMO) Plans?


In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don't require a referral.


What else do I need to know about this type of plan?


  • If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.
  • If you get health care outside the plan's network , you may have to pay the full cost.
  • It's important that you follow the plan's rules, like getting prior approval for a certain service when needed.What is a Medicare HMO?


 

HMO Basics


 

Medicare Health Maintenance Organizations (HMOs) are private plans that the federal government pays to administer Medicare benefits. Like all Medicare Advantage Plans, HMOs must provide you with the same benefits, rights, and protections as Original Medicare, but they may do so with different rules, restrictions, and costs. Some HMOs offer additional benefits, such as vision and hearing care.


Eligibility and costs basics


You must have both Parts A and B to join a Medicare HMO. Generally you will continue paying your Medicare Part B premium, though some HMOs will pay part of this premium. Some HMOs may charge an additional premium, on top of your Part B premium. If you want Part D coverage, you will receive it through your HMO. Plans may charge a higher premium if you also have drug coverage.

Note: If you join a Medicare Advantage Plan and you want Part D coverage, you must receive coverage from your plan. You cannot enroll in stand-alone Part D coverage unless you join a Medical Savings Account (MSA) or Private Fee-for-Service (PFFS) plan that does not offer prescription drug coverage.


Typically you cannot have an HMO if you have End-Stage Renal Disease (ESRD), unless:


  • You join a Special Needs Plan (SNP) HMO that specifically takes beneficiaries with ESRD
  • Or, you were enrolled in an HMO prior to developing ESRD and you choose to stay in that HMO


Note: If you remain enrolled in an HMO after developing ESRD and the plan leaves your area, you have a Special Enrollment Period (SEP) to enroll in another HMO in your area.


Benefits access basics


Once you have joined an HMO, you should receive a benefit card from your plan. You will use your HMO benefit card instead of your Medicare card when you go to the doctor or hospital.


In most HMOs, you must see in-network providers to receive coverage, unless you need emergency medical treatment. Some HMOs offer a point-of-service (POS) option, which allows you to go out of network for certain services. In these cases, you will be covered but usually at a higher cost.


 

 

Specialists & referrals in Medicare Advantage Plans


Health Maintenance Organization (HMO) Plans


In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don't require a referral.


Preferred Provider Organization (PPO) Plans


In most cases, you don't have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.


Private Fee-for-Service (PFFS) Plans


You don't have to get a referral to see a specialist in PFFS Plans.   


Special Needs Plans (SNPs)


In most cases, you have to get a referral to see a specialist in SNPs. Certain services don't require a referral, like these:

  • Yearly screening mammograms
  • An in-network pap test and pelvic exam (covered at least every other year)

 
 

Choosing primary care doctors in Medicare Advantage Plans


Do I need to choose a primary doctor in Health Maintenance Organization (HMO) Plans?


In most cases, yes, you need to choose a primary care doctor in HMO Plans.


Do I need to choose a primary doctor in Preferred Provider Organization (PPO) Plans?


You don't need to choose a primary care doctor in PPO Plans.


Do I need to choose a primary doctor in Private Fee-for-Service (PFFS) Plans?


You don't need to choose a primary care doctor in PFFS Plans. 


Do I need to choose a primary doctor in Special Needs Plans (SNPs)?


In most cases, SNPs may require you to have a primary care doctor. Or, the plan may require you to have a care coordinator to help with your health care.