Medicare HMO

Medicare HMOs are relatively popular Medicare Advantage plans because of their lower premiums. Some plans even have a $0 premium. However, there are other costs implied like your Part B premium. The reason these plans tend to be cheaper is that it is very difficult to see a non-network provider. Furthermore, you would need a referral from your primary care provider in order to see a specialist.

What is a Medicare HMO?

HMO is a health maintenance organization coordinated care plan through which you would receive your Medicare benefits. The insurance company works with some physicians in your local area– forming a network. Within this network, you choose a primary care physician (PCP) to coordinate your services.

If your PCP is unable to treat a health condition, he or she will issue a referral for you to see a specialist network. Some services like preventive care, mammograms and emergency visits may not require a referral.

As mentioned before, you will still have to pay the Part B premium. You must be enrolled in both Medicare Parts A and B in order to enroll in any Medicare Advantage program. You must also live in the plan’s service area.

Again, in an HMO plan, you can only obtain service from network providers except if it’s an emergency. However, some plans have a Point-of-Service feature. In a POS plan, you can use some non-network providers under certain circumstances, like when you’re traveling. You would pay the same in-network cost-sharing amount. However, these these features work may vary, so be sure to check the details of your plan. A Medicare Advantage PPO is a less restrictive version of an HMO in that you do not need a referral to see a specialist under your network and you may see any provider who accepts Medicare. 

Medicare HMO plan Common Features

  • Medicare HMO plans cannot ask you health-related questions other than whether or not you have End-Stage Renal Disease.
  • Formularies, pharmacy and provider networks, co-payments/co-insurance, and premiums can change every January 1st so it’s important to always review your Annual Notice of Change letter each fall 
  • A local network of health care providers and hospitals from which you must seek your care, except in emergencies.
    • Many plans will have you choose a primary care physician who can coordinate a referral to send you to a specialist.
    • There are some HMO-POS plans.
  • Many HMO plans cover Medicare Part D. If so, be sure to check the plan’s drug formulary to make sure your medications are included.
  • You pay co-pays or coinsurance. You can see how much the provider is allowed to charge for certain services in each plan’s benefits summary.

How to Choose a Medicare HMO plan

It takes a lot of effort to look through all the different HMO plans. That’s why you should consider getting help from an agent like us. We are very familiar with these plan’s provider networks and service areas, so we can help you find a suitable one for you. We can also go over plans’ star ratings with you

Feel free to give us a call at 212-484-9888. Or if you’re on mobile, click the button:      Call Now!