Medicare Advantage HMO Plans

Medicare Advantage HMO plans typically have lower monthly premiums than other Medicare Advantage plans. They also have more restrictions on the healthcare providers you can see.

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Medicare HMO Plans

Some Medicare Advantage plans are Health Maintenance Organizations or HMOs. Every HMO has a network of doctors that provide services to the HMO members. If you have insurance through an HMO, you must choose a primary care doctor within the HMO network. This doctor will coordinate care and refer you to a specialist within the network when necessary.

Other features of HMO plans include:

  • Referral from your primary care doctor to see a specialist
  • The doctors in the network will usually be in your local area
  • If you go to a provider outside the network (other than in an emergency), you pay the full cost.

Many people overlook these restrictions since HMO coverage is usually less expensive than other Medicare Advantage coverage or even Medigap plans.

Some HMOs don’t have a monthly premium other than the standard Part B premium.

Except for emergencies, you must see healthcare providers in your network. Some HMO plans have an additional point of service or “POS” feature that allows you to go outside the network in certain situations, such as while you are traveling.

Because HMOs are sold by individual insurance companies, different plans will have different copays, coinsurance, and networks of providers. Many HMOs also include prescription drug coverage.

Eligibility for Medicare Advantage HMOs

Anyone who has Medicare and lives in the HMO plan’s service area is eligible to join the plan, with one exception: people with End-Stage Renal Disease usually cannot join an HMO.

You can join an MA plan when you first become eligible for Medicare, this is the Initial Enrollment Period. Beneficiaries can also enroll during the Annual Enrollment Period from October 15 through December 7 each year.

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In some situations, you may qualify for a Special Enrollment Period and be allowed to join a plan at other times.

What are the Differences Between an HMOs and PPOs?

PPOs, or preferred provider organizations, are another type of MA policy you can buy. Like an HMO, a PPO has a network of doctors.

There are several important differences between HMOs and PPOs:

With a PPO, you usually don’t have a primary care doctor, and you can see a specialist without a referral. HMOs require a referral from your primary care doctor.

While HMOs require you to see providers in the plan’s network, many PPOs provide some insurance coverage if you decide to use an out-of-network provider. However, your costs will be higher if your provider is outside the plan’s network.

PPOs tend to have higher monthly premiums than HMOs.

Is Medicare Advantage HMO different than Original Medicare?

An HMO Medicare Advantage plan is an alternative to Original Medicare.

Although all Medicare Advantage plans cover the same services as Medicare, there are a couple of significant differences.

  • Medicare doesn’t have doctor networks
  • You cannot buy a Medigap plan if you have an MA plan
  • Depending on the plan you choose, an HMO may have lower premiums
  • Many MA plans include Part D
  • Medicare doesn’t include medicines, but you can buy Part D

What are the Disadvantages of HMOs?

The biggest disadvantage is the doctor network. For example, if your doctor leaves the network, you need to find a new doctor. Or, if a healthcare facility leaves the network, you may need to find a whole new place for care.

Another thing, you most likely need a referral to see a specialist. So, you’ll need to pay a copay for the primary doctor and for the specialist.

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How to Get Help Understanding Medicare HMO Plans

HMO plans have plenty of restrictions. People who travel, have specific doctor requirements or those that need more flexibility will be unhappy with an HMO policy.

Some people will benefit more from Medigap coverage than from Advantage coverage. We all have different needs and requirements; call us at the number above to discover your best policy.

If you’re looking for the best Medicare coverage, let MedicareFAQ do the legwork for you. We’ll search the top insurance companies in your area and give you a free, no-obligation quote.

To get started, fill out an online rate comparison form or call us at the number above.

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Jagger Esch

Jagger Esch is the Medicare expert for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.

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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