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Posted 12/27/2021 in Category 1

Medicare Advantage HMOs

Medicare Advantage HMOs

Medicare Advantage HMOs

If you are considering a Medicare Advantage plan, you have a few different types to choose from. A Medicare Advantage plan is a popular option among Medicare beneficiaries because they are known for having affordable monthly premiums. However, make sure you know the ins and outs of these plans before enrolling. 

What is an HMO?

A Health Maintenance Organization (HMO) is a type of managed care insurance plan. The goal of these plans is to offer affordable healthcare while still giving quality care. They do this by contracting with facilities, primary care physicians, and specialists. The HMO carrier pays each provider to offer services to their HMO plan members.

Requirements of HMO Plans

A Medicare Advantage can be a wonderful asset for many Medicare beneficiaries, as long as you are aware of the requirements set by the plan. Every HMO plan has the same three requirements, but some may have more. Refer to your plan details for the specific requirements of your plan.

Provider Networks

This is the most notable requirement of an HMO plan. Members of HMO plans must receive care from providers and facilities within the plan's network. If you see a provider who is not in-network with your HMO plan, you will have no coverage, and you will be responsible for paying the entire bill. Ouch!

If you need emergency services, there can be some exceptions to this rule.

Primary Care Provider

You will also be required to designate a Primary Care Provider or PCP. Your PCP will coordinate all of your care moving forward. While this can seem like a limitation, the requirement is supposed to give you continuity of care. Your PCP will stay informed about all of your medical visits, so they will have a complete picture of what is going on with your health.

Specialist Referrals

Lastly, your PCP will also need to give you a referral if you need to see a specialist. They will refer you to a provider who is also part of the HMO network, and your PCP and the specialist will communicate about your care.

What is an HMO-POS?

There is one other type of HMO called an HMO-POS. POS stands for Point-of-Service. These HMO plans have some unique features not found in a regular HMO.

With an HMO-POS plan, you will have some out-of-network benefits. However, the coverage level will not be as high as it is with an in-network provider, and your deductible may also be higher. That means that you will pay more out-of-pocket than you would if you see an in-network provider, but some benefits are better than none! Also, with an HMO-POS plan, you can see a specialist without a referral from your PCP.

Medicare Advantage HMO: Costs and Coverage

There are several costs associated with an HMO plan. While every plan varies in cost and coverage, we'll give you an idea about what to expect from an HMO here.


Medicare Advantage HMO plans are one of the lowest-premium plans on the market. Some even have $0 premiums. (You still have to pay the Part B premium.) Even if your HMO plan's premium isn't $0, it is likely to be very affordable. Generally speaking, an HMO premium will be less than an HMO-POS premium.


An HMO's deductible can be as low as $0. Again, this varies based on the specific plan. And remember, if you do enroll in an HMO-POS, your deductible could be higher for out-of-network providers. Also, you may have a separate deductible for prescriptions, which we'll discuss in a moment.


HMO plans set their own copays for doctor's visits. These range from $0 to $50 for each visit. Once you've paid your copay and any associated deductible, most Medicare Advantage HMO plans pay for about 80% of the cost of covered services. There is usually an out-of-pocket maximum that applies to these plans as well.

Prescription Costs

Not every Medicare Advantage HMO plan includes prescription drug coverage. If yours does, you may have a separate deductible that applies. (No prescription drug deductible can exceed $480 in 2022, but your plan could have a lower amount.) Coinsurance amounts will be based on the plan's drug formulary.

If your HMO plan does not include drug coverage, you'll need to enroll in a separate Part D prescription drug plan. Your Part D plan will include a premium, deductible, and coinsurance amounts.

Pros and Cons of Medicare Advantage HMOs

By now, you can probably see that there are some pros and cons of enrolling in a Medicare Advantage HMO plan. Let's review!

Pros of a Medicare Advantage HMO

Most Medicare Advantage HMO plans come with a low premium, some even as low as $0 per month. HMO plan members also have access to more services than those with Original Medicare (Parts A and B) alone.

Cons of a Medicare Advantage HMO

HMO plan members are limited to a network of providers. In more rural areas, this could mean very limited choices. However, in some bigger cities, there are many providers who participate in HMOs. You may need to switch providers to find one who participates in the HMO network. Also, your provider could leave the network at any time, so you'll need to be flexible when it comes to your healthcare team.