Ron Elledge is a seasoned Medicare consultant and author of “Medicare Made Easy.” As a Medicare expert, he regularly consults beneficiaries on Medicare rules, regulations, and strategies.
Kelly Blackwell is a Certified Senior Advisor (CSA)®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.
If you are enrolled in Medicare Parts A and B, you can move beyond the basic coverage provided by Original Medicare and choose to purchase additional benefits via one of the Medicare Advantage (MA) Plans available in your area. There are several different types of Medicare Advantage Plans. All are provided through Medicare-approved private insurance companies, and each type of plan has its own structure.
One of the most popular of these MA plans is the Health Maintenance Organization (HMO). When you join an HMO, you choose a primary care physician (PCP) from the HMO’s selection of in network physicians. Your PCP will manage your care through the HMO’s network of facilities and doctors.
HMO plans are generally among the least costly of the Medicare Advantage Plans. Continue reading to learn more about what these plans offer and whether one is right for you.
What is a Medicare HMO Plan?
Medicare HMO plans provide you with access to your Medicare-covered services through a specific network of physicians and facilities. HMO’s are often called managed care plans because your primary care physician (PCP) is responsible for managing your care. Your PCP provides the majority of your treatment and provides referrals for care from in network specialists for services that they do not provide. Every Medicare HMO plan is different; the network of physicians is the prevailing feature. Some HMO plans may not require referrals for all specialists, for emergency services, or for regular preventive care services such as mammograms.
|Advantages of a Medicare HMO plan||Disadvantages of a Medicare HMO plan|
|Health Maintenance Organization plans were created to offer cost savings to Medicare beneficiaries, and the reduced expense is one of the primary advantages of selecting a Medicare HMO plan. Choosing an HMO reduces the need to fill out time-consuming paperwork or claim forms. Once you provide your proof of insurance card at the point of service, there is no need to complete or submit any further claims. You have the security of knowing that your health care expenses will be limited to a fixed monthly premium; plus deductibles, copayments, and coinsurance charges which vary depending upon the services received.||Though choosing an HMO provides you with reduced costs, the savings come at the expense of your freedom of choice. In traditional HMO’s you are required to identify a primary care physician who is your point of contact for all services. The PCP must provide a referral for specialty care, and the specialty care provider will also need to be from within the HMO’s existing network. Some HMOs do permit you to seek specialty care without a referral and from outside of the network, but your costs will be higher. The same restrictions exist for the hospitals and medical facilities where you can be treated. With the exception of emergency treatment, in most cases if you choose to seek care from a non-network provider or facility you will have to pay the full cost of your care out of pocket.|
Who is Eligible for a Medicare HMO Plan?
A Medicare HMO is one of several types of Medicare Advantage Plans available to Medicare beneficiaries. In order to sign up for a Medicare HMO plan you must first have signed up for Medicare Part A and Part B coverage.
To be eligible for Medicare you must either have turned 65 years old and be either a U.S. citizen or a legal resident for at least five years. Those who are under 65 may also be eligible if they have been receiving disability benefits from either Social Security or the Railroad Retirement Board for a minimum of 24 months. Those diagnosed with ALS (Lou Gehrig’s disease) and End Stage Renal Disease (ESRD) are eligible for Medicare as soon as disability benefits begin.
How Much Does a Medicare HMO Plan Cost?
The amount that you will pay to enroll in a Medicare HMO plan will depend upon several different factors. Because every plan is different, you need to ask the following questions:
- Is there a monthly premium, and if so, how much is it?
- Does the plan pay all or part of the Medicare Part B monthly premium?
- Is there a yearly deductible, and if so, how much is it?
- What is the copay/coinsurance that is charged for each visit or service?
- What is the annual limit on how much you will pay in out-of-pocket costs?
Beyond asking these questions, if you are considering an HMO you should think about your own medical and health care needs. If you have pre-existing medical conditions and require specialty care, you need to consider whether you are likely to follow the plan’s rules and restrict yourself to only using network providers. If you choose to receive care out-of-network,, you may want to ask whether the provider will accept the assignment. If not, consider whether it is worth it to you to pay the additional out-of-pocket expense to receive care.
How Do I Enroll in a Medicare HMO Plan?
To enroll in a Medicare Advantage Plan, you first must have Medicare Part A and Part B. Following this step, you can only sign up for a Medicare HMO plan during either your Initial Enrollment Period or during certain enrollment periods that happen each year, though there are Special Enrollment Periods available under certain circumstances.
- Initial Enrollment Period – Once you turn 65 you become newly eligible for Medicare. The Initial Enrollment Period refers to a seven-month period that begins three months before the month you turn 65, the month in which you turn 65, and the three months after the month in which you turn 65.
- Initial Coverage Enrollment Period (ICEP) – This enrollment period is for those enrolling in a Medicare Advantage Plan. For most, this period occurs at the same time as their Initial Enrollment Period for Original Medicare Parts A and B. But, for those who delay their Part B enrollment, the ICEP for Medicare Advantage begins the three-month period before their Part B start date and ends the last day of the month before their Part B coverage starts. If enrollment happens even one day after Part B begins, you will have to wait until the next AEP to enroll in a Medicare Advantage Plan.
- Annual Enrollment Period – There are two enrollment periods that occur every year during which you can enroll in a Medicare HMO plan or make changes to an existing plan. The first is between October 15th and December 7th. During that time Medicare Advantage-eligible individuals may enroll in, dis-enroll from, or change to another Medicare Advantage plan. There is also a Medicare Advantage Open Enrollment Period between January 1st and March 31st. During that time Advantage Plan members can make only one change (such as switching from one Medicare Advantage Plan to another, or disenrolling from their Advantage Plan). The MA-OEP is not for non-Advantage Plan members. Non-members cannot enroll in MA Plans during this period.
- Special Enrollment Periods – These enrollment periods are available to you if you have experienced specific events such as moving to an area that is not in your plan’s service area or losing your insurance coverage as a result of a job loss.
When you are ready to sign up for a Medicare HMO plan, you can do so online.
Who Should Get a Medicare HMO Plan?
Each type of Medicare Advantage plan offers its own advantages and disadvantages. A Medicare HMO plan makes the most sense if you are looking for the lowest possible monthly premiums, don’t travel much, or need a great deal of speciality care.
HMOs may not be a fit if you are looking for freedom of selection of doctors, hospitals, and clinics, or are concerned with a known budget for your yearly cost of health care. If you prefer to stay with your own physician or to make your own decisions about what specialists you want to see, it is a good idea to review your HMO’s list of in-network physicians to see whether your favorites are on the list. Remember that if they leave the network, you will not be able to follow them without switching plans during the next AEP or MA-OEP or incurring additional charges.
Learn More From Our Sources
- CMS | Fact Sheet 2021 Medicare Part A & B Premiums and Deductibles | Last accessed September 2021
- Medicare | Common Types of Medicare Advantage Plans | Last accessed September 2021
- Medicare | What Medicare Covers | Last accessed September 2021
- Medicare | Your Medicare Costs at a Glance | Last accessed September 2021
- Social Security Administration | Benefits Planner | Last accessed September 2021