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HMO | Health Maintenance Organization

What is an HMO plan?

Medicare Advantage HMO Plans

1) Beneficiaries who enroll in an HMO plan are required to see providers, doctors, and hospitals within the plan’s network except in urgent care or emergency situations.
You will need to choose a primary care physician (PCP) when enrolling in most HMO plans, and most of the time if you need to see a specialist your PCP will have to give you a referral. Some services such as mammograms do not require a referral.

2) HMOs must offer all of the same benefits that are available to you under Original Medicare, however, some HMOs may offer additional benefits that Original Medicare does not cover such as hearing, dental or eye care.
Many plans also offer Prescription Drug Coverage (Part D). If you are enrolled in a Medicare Advantage HMO plan you must get your drug coverage from that plan. With Original Medicare, a beneficiary generally pays only the premium amount for Part B. HMO plans may charge a monthly premium in addition to the Medicare Part B premium. You must continue to pay your Part B premiums if you are enrolled in a Medicare Advantage plan.

3) With an HMO plan you usually pay a fixed amount for services (co-pay), but the co-payment cannot be higher than Original Medicare charges for certain services such as chemotherapy, dialysis, and durable medical equipment.
However, it can be higher for other services such as hospital care and home health services. HMOs must have a cap on out of pockets costs to protect the beneficiary against high costs if your care becomes too expensive.

4) If you are generally healthy and only see doctors and seek care at facilities that are in your HMO provider network, your out of pocket costs may be lower than if you just had Original Medicare.
The key is to make sure that your providers are within the plan’s network because if you do not your plan may not cover the cost and you will be responsible. This could be damaging to your finances if you were to need a lot of care or expensive treatments that weren’t covered under your plan. If your physician were to leave the plan’s network of providers you would be notified of this departure and you will.

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