As a general rule, you will be required to receive your medical care and health-related services from providers that exist within the plan’s network, with some exceptions. Exceptions to this rule include:
- Emergency care
- Urgent care that is outside of your service area
- Dialysis treatments that are outside of your service area
For your regular care, you may be required to choose a primary service provider from a list of doctors within the plan’s network. If you need to see a specialist, you will need to get a referral from your primary care physician. However, standard annual procedures such as mammograms will not require a doctor’s referral.
Some HMO Medicare Advantage Plans allow you to seek services from a provider that is not in their network. These are HMO Plans with a POS option (point of service). In these cases, out-of-pocket expenses may be higher.
Prescription drugs are generally covered with an HMO plan, but be sure to check in with a licensed Medicare agent to be sure.