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What Is a Medicare HMO Plan?

Updated: Nov 25, 2020

Medicare Advantage plans are private health insurance plans available to seniors who qualify for Medicare. These plans cover Parts A and B of Medicare insurance and typically also include prescription drug coverage and other services such as hearing and dental that Original Medicare does not cover. Medicare Health Maintenance Organization (HMO) Plans are one of four common kinds of Medicare Advantage plans. The other three common types are:

A Medicare agent at PBC can help you learn about whether a Medicare HMO plan is right for you. In this article we’re going to take an overall look at Medicare HMOs and how they work.

How Medicare HMOs work

Like all types of Medicare Advantage Plans, HMOs must provide seniors with the same benefits, rights, and protections as Original Medicare. They are, however, allowed to provide them with different restrictions, rules, and costs. Some HMOs offer extra benefits, such as vision and hearing care. Check with a Medicare Agent for plan details.

Can I join a Medicare HMO?

In order to qualify for a Medicare HMO Plan, you must already be enrolled in Medicare Parts A and B. In most cases, you will continue paying your Medicare Part B premium. Some HMOs pay part of this premium while others may charge an additional premium, on top of your Part B premium. One reason that a plan would charge an additional premium is if it includes prescription drug coverage.

On a Medicare HMO do I have to get care within the HMO network?

Before enrolling, you should know whether you can seek medical care from any medical provider or hospital or if you must remain within a network. When it comes to a Medicare HMO, you will generally need to get your care and medical services from physicians and/or hospitals within the Medicare HMO network. If you receive health care services from a doctor or hospital outside the plan's network, you may have to pay the full cost. The exceptions to the rule are for emergency or urgent care and if you need out of area dialysis for ESRD.

Do I need to have a primary care physician if I choose a Medicare HMO?

Most Medicare HMOs do require that their members select a Primary Care Physician (PCP).

Will I need to get a referral to see a specialist?

Apart from certain cancer screenings such as annual mammograms, you will generally need to get a referral to see a specialist on a Medicare HMO. Enrollees will want to gain prior approval for certain services when needed in order to ensure their care will be covered by the plan.

Will I get prescription drug coverage on a Medicare HMO?

Most HMO Plans do cover prescription drugs but you will want to speak with your Medicare Agent to confirm that you are choosing an HMO with Medicare drug coverage (Part D) if you require it. This is because you cannot purchase Medicare Part D as a standalone plan when you have an HMO.

Our independent insurance agents are dedicated to assisting people on Medicare and those who are ready to transition from employer coverage to personal retirement coverage. We help kupuna understand their benefits options and apply for additional coverage, as needed. Because we represent all the major Medicare Advantage and supplement plans in Hawaii, we are able to offer unbiased advice; all at no cost to our clients.

At PBC, our clients are our number one priority and we look forward to getting to know you and your needs. Call us today at (808) 738-4500 to see how we may be of assistance.

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