HMO Plans
What Is a Medicare Advantage HMO Plan?
Some Medicare Advantage (Part C) plans are Health Maintenance Organizations (HMOs). These plans are an alternative to Original Medicare and are sold by individual insurance companies. Every HMO has a doctor network that provides services to plan members. Keep reading to learn more about HMOs and see if this type of plan is right for you.
HMO Plans at a Glance
If you have insurance coverage through an HMO, you have to choose a primary care doctor within the plan’s network — who will coordinate your care and refer you to a specialist (within the network) when it’s necessary.
The doctors in the HMO network will typically be in your local area. If you see a provider outside the network (unless it’s an emergency), you pay the FULL cost.
Some HMOs do not have a monthly premium besides the standard Medicare Part B premium. Different HMO plans will have different networks of providers, as well as different copays and coinsurance. Many HMOs include prescription drug (Part D) coverage.
Lower Monthly Premiums
HMOs try to keep plan members healthy by offering a copayment for most doctor visits. They also usually have lower monthly premiums than other Advantage plans. However, with that comes more restrictions on the healthcare providers you’re able to see.
Get the right coverage at the right price.
Who Is Eligible for a Medicare Advantage HMO Plan?
Anybody who has Original Medicare and lives in the plan’s service area is able to join the HMO plan, except for people with End-stage renal disease (ESRD).
You can join a Medicare Advantage plan during your Initial Enrollment Period, which occurs when you first become eligible for Medicare. You can also sign up during the Annual Enrollment Period from October 15 to December 7.
In certain situations, you may be eligible for a Special Enrollment Period and be permitted to join an HMO plan at other times.
The Disadvantages of HMOs
The main drawback of HMOs is the doctor network. For instance, if your doctor leaves the network, you’ll need to find a new doctor. If a medical facility leaves the network, you may need to find a new place for healthcare.
Also, you typically need a referral to visit a specialist — meaning you’ll pay a copay for the primary physician and for the specialist.
HMOs vs. PPOs
Medicare Advantage PPOs are another kind of Advantage plan that you can buy. A PPO also has a network of providers, but there are important differences between PPOs and HMOs.
With a PPO, you typically don’t have a primary care doctor and you can go to a specialist without a referral. HMOs require a referral from your doctor.
Several PPOs provide some coverage if you use an out-of-network provider, while HMOs require you to stay in the plan’s network. However, for PPOs, you’ll pay more if your provider is outside the network. PPOs tend to cost more than HMOs.
PPO
HMO
Gives you more flexibility
Have more restrictions
Usually costs more
Usually costs less
Can see a specialist without a referral
Need a referral from your primary care doctor
The Bottom Line
Medicare Advantage HMO plans have restrictions that should not be overlooked. If you travel, have certain doctor requirements, or need more flexibility in managing your care, we recommend a PPO instead of an HMO.
With that in mind, Medicare Advantage plans aren’t right for everyone. Medigap coverage (Medicare Supplements) may work better for some people. The best policy for you depends on your needs and situation, so call Oak Haven Insurance Agency to find your best options.
