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Medicare Advantage HMO Plans

Summary: Medicare Advantage HMO plans often offer attractive low-cost healthcare coverage options. With a Medicare HMO, you receive all the same coverage as Original Medicare (Medicare Part A and B) but from private insurance companies, not the federal government. While the benefits of an HMO may be great for some, others may not like the out-of-pocket costs. It’s important to compare all of the healthcare options near you before enrolling. Estimated Read Time: 6 mins

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Table of Contents:

  1. What Is a Medicare Advantage HMO Plan?
  2. How Does an HMO Plan Work?
  3. Why Are HMO Plans Popular?
  4. Eligibility for Medicare Advantage HMOs
  5. Is Medicare HMO the Same as Medicare?
  6. Benefits of an HMO Plan
  7. How To Find the Right Medicare HMO Plan for You

Medicare HMO plans typically offer lower monthly premiums than other Medicare Advantage plan types. However, lower premiums come with less flexibility. This means that while attractive, a Medicare Advantage HMO may not be a suitable option for your healthcare needs.

Medicare Advantage HMOs often advertise additional benefits you can’t get with just Original Medicare (Medicare Part A and Part B) alone. However, this can vary greatly from ZIP Code to ZIP Code, plan to plan, and carrier to carrier. So, while many can benefit from Medicare HMOs, it’s important to explore all options.

Everyone has different healthcare needs and it’s important to weigh both the pros and cons before enrolling. Learn about Medicare Advantage HMO plans and how you may be able to benefit from their coverage below.

What Is a Medicare Advantage HMO Plan?

Health Maintenance Organizations, or HMO plans are offered by private insurance carriers and covers all the benefits of Original Medicare (Parts A and B) covers but may also cover additional healthcare costs. These additional benefits may vary from plan to plan and may not be applicable in all ZIP Codes.

There are several different types of Medicare Advantage plans available and Medicare HMOs use a network of doctors providing services to its members.

How Does an HMO Plan Work?

You must choose a primary care doctor within your plan’s network if you have insurance through a Medicare HMO plan. This doctor will coordinate care and provide referrals when necessary to see a specialist.

The doctors in your network will usually be in your local area. If you go to a provider outside the network (other than in an emergency), you’ll have to pay the total cost out-of-pocket. Because private insurance companies sell Medicare HMOs, each plan will come with a different copay, coinsurance, and provider network.

Some Medicare HMO plans may have an additional point of service or POS feature that allows you to go outside the network in certain situations. For example, while you are traveling. But this also varies among each of the HMO Medicare plans.

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Medicare HMOs are different from Medicare PPOs. With a Medicare Advantage PPO (Preferred Provider Organization), beneficiaries can use doctors and facilities outside their network, albeit at a higher cost. With a Medicare Advantage PPO (Preferred Provider Organization), beneficiaries can use doctors and facilities outside their network, albeit at a higher cost.

A PPO plan usually has higher premiums than a Medicare Advantage HMO plan. Further, unlike a Medicare HMO plan, Medicare Advantage PPO plans do not require a referral to see a specialist in most cases.

Why Are HMO Plans Popular?

An HMO Medicare Advantage plan can be popular for many reasons including greater access to healthcare, lower premiums, and potentially, the additional benefits they offer. However, a Medicare HMO is often more popular with those who can find coverage with a network already including their doctor.

Remember, any HMO Advantage plan will come with network restrictions. Many overlook these restrictions since HMO plans for Medicare have lower premiums than other Medicare Advantage plans or Medicare Supplement (Medigap) plans. Additionally, some Medicare Advantage HMOs don’t have a monthly premium aside from the standard Medicare Part B premium.

Because HMO plans are popular with those who find coverage with their doctors in network, the other features can be a great option. Still, there are out-of-pocket expenses and many other considerations anyone should review before enrolling.

Eligibility for Medicare Advantage HMOs

Anyone with Medicare who lives in an HMO plan’s service area can join the plan, including those with End-Stage Renal Disease (ESRD).

You can join a Medicare Advantage HMO plan when you first become eligible for Medicare during your Initial Enrollment Period. When eligible for Medicare, you can also enroll during the Annual Enrollment Period from October 15 through December 7 each year.

In some situations, you may qualify for a Special Enrollment Period. In this case, a qualifying life event – such as moving or losing your coverage – affords you the opportunity to enroll in a Medicare Advantage plan when you would otherwise be unable.

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Keep in mind, while you can enroll in a Medicare HMO plan if you have a Medigap plan, you can’t have both at the same time. Therefore, if you wish to switch, you’ll need to wait until the Annual Enrollment Period to disenroll from your Medicare Supplement plan and enroll in a Medicare HMO plan.

Is Medicare HMO the Same as Medicare?

Medicare HMOs and Medicare are not the same. Medicare itself is a health insurance program provided by the federal government. Medicare HMO plans are a type of Medicare Advantage plan that falls under this program’s umbrella, offered by private insurance carriers.

Medicare Advantage HMO plans are also often thought to be an alternative to Original Medicare and while they cover the same services as Parts A and B, there are some significant differences:

  • Original Medicare doesn’t have doctor networks
  • Many Medicare Advantage plans may include Medicare Part D through a Medicare Advantage Prescription Drug Plan
  • Original Medicare doesn’t include medicines, but you can buy a Medicare Part D prescription drug plan to use alongside your Part A and Part B coverage

Benefits of an HMO Plan

Understanding the benefits of an HMO Advantage plan can help you make an informed decision for your healthcare. Here are some of the advantages may beneficiaries enjoy:

  • Lower premiums and lower out-of-pocket costs than Medicare Advantage PPO plans
  • If your HMO has prescription drug coverage it is also often less expensive than other options
  • A great option for many who are in good health and rarely see their doctor
  • HMO Advantage plans are also attractive for those who travel less
  • Members typically receive whole-patient care from their primary physician

Keep in mind that not all Medicare Advantage HMO plans may have the same advantages and the benefits above are meant more as an overview. Always review the Medicare HMO plans list in your area and other forms of healthcare coverage to ensure you are enrolling in the right plan for your needs.

How To Find the Right Medicare HMO Plan for You

If you’re looking for the best Medicare coverage, let us do the legwork. We’ll search the Medicare HMO plan list in your area and give you a free, no-obligation quote.

For some, Medigap coverage may be a better option than a Medicare Advantage plan. It all depends on your budget, healthcare needs, and lifestyle. Our agents help you find the right choice accordingly. Call us at the number above to discover the right solution for you.

Unable to call? Fill out our online rate comparison form to get started. Whether it’s a Medicare HMO plan, PPO coverage, or Medigap, we are committed to delivering the right solution for your healthcare.

Kayla Hopkins

Kayla Hopkins

Content Editor
Kayla Hopkins is an accomplished writer and Medicare educator serving as the Editor of MedicareFAQ.com. Upon completing her Communications degree from Ohio University, Kayla dedicated her time to understanding the ever-evolving landscape of healthcare. With her extensive background as a Licensed Insurance Agent, she brings a wealth of knowledge and expertise to her writing.
Ashlee Zareczny

Ashlee Zareczny

Compliance Manager
Ashlee Zareczny is the Compliance Manager for MedicareFAQ. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.

2 thoughts on "Medicare Advantage HMO Plans"

    1. Hi Sheldy! The list of providers depends on the carrier you enroll with. There should be information in your summary of benefits that tells you where to find the plan’s directory of doctors in the plan’s network.

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