Medicare Advantage HMO Plans

If you are planning on enrolling in Medicare, you might be considering either original Medicare with add-ons or a comprehensive Medicare Advantage plan.

There are a handful of different types of Medicare Advantage plans, but the most popular are the Health Maintenance Organization (HMO) plans. If you enroll in a Medicare Advantage HMO, your care will be provided by in-network providers.

Let’s look at what Medicare Advantage HMO plans offer, how to enroll, and some of the advantages and disadvantages of choosing a Medicare Advantage HMO plan over original Medicare.

Medicare Advantage (Part C) is a type of Medicare plan that is offered by private insurance companies. With Medicare Advantage plans, you are covered for Medicare Part A, Medicare Part B, and some additional health coverage options, such as prescription drugs, dental, vision, and more.

Medicare Advantage offers different plan structures, such as HMOs, Preferred Provider Organizations (PPOs), Special Needs Plans (SNPs), and more.

All Medicare Advantage HMO plans must cover at least:

• Part A services: including hospital insurance, hospice care, and limited skilled nursing facility and home healthcare
• Part B services: including preventive care and tests, necessary home medical equipment, outpatient procedures, and more

Most Medicare Advantage HMO plans also include:

• prescription drug coverage (Medicare Part D)
• dental, vision, and hearing coverage
• additional health coverage, such as home meal delivery or fitness memberships

To enroll in a Medicare Advantage HMO plan, you must already be enrolled in Medicare parts A and B. Once this is done, you are eligible to enroll in a Medicare Advantage HMO plan in your state.

How do Medicare Advantage HMOs work?

Medicare Advantage HMOs are based around in-network medical care. This means that you are given a list of in-network providers to choose from when you need medical services. If you decide to select a provider who is out of network, you may owe a higher cost or the full out-of-pocket amount for those services.

An exception to this rule is if you need emergency care or are traveling and require urgent care or a dialysis visit. When you enroll in your plan, you will be provided a list of in-network providers and specific rules regarding out-of-network care.

There are some types of Medicare Advantage HMO plans that allow you to seek services from out-of-network providers. These Point-of-Service (POS) plans usually have different rules than regular HMO plans.

Let’s take a look at some of the advantages and disadvantages of enrolling in a Medicare Advantage HMO plan.

Advantages of Medicare Advantage HMOs

HMO plans are a popular choice among Medicare Advantage plans, which means plenty of variety in available options. In most major cities, you can easily find plans that have low-cost premiums, deductibles, and copayments.

The popularity of Medicare HMO plans also means that you will have a wide in-network selection of providers to choose from.

Disadvantages of Medicare Advantage HMOs

There is less provider flexibility with HMOs compared with other Medicare Advantage plans. You will be required to choose a primary care physician (PCP) when you enroll in the plan, which may mean switching from your current doctor.

Referrals are required for any specialist visits, which means taking the time to visit with your primary doctor to get the referral first. Outside of emergency situations, you will owe higher costs if you seek services outside of your plan’s network.

Medicare Advantage HMO plans can be a great way for Medicare beneficiaries to save money on healthcare costs. Here are some of the costs to consider as you choose your plan.

Premiums

Medicare Advantage HMO plans may have their own monthly premium, unless they are premium-free plans. Your Medicare Advantage HMO plan doesn’t cover the Part B premium, so you’ll pay this amount in addition to any premium that comes with your HMO plan.

Deductibles

Medicare Advantage HMO plans generally have their own in-network deductible amounts, which can start as low as $0. If your plan covers prescription drugs, you can expect to see a drug deductible amount, as well.

Copayments

When you enroll in a Medicare Advantage HMO plan, there are different copayment amounts for PCP and specialist visits. Copayments can range from about $0 to $50 per visit, depending on the plan and provider.

Coinsurance

After the yearly plan deductible has been met, you’ll usually pay 20 percent of the Medicare-approved costs for the services you receive.

Out-of-pocket max

All Medicare Advantage HMO plans have an out-of-pocket max that you will be expected to pay. This amount varies based on the details of your plan.

Cost comparison for Medicare Advantage HMOs in several U.S. cities

When comparing Medicare Advantage HMO plans in your state, consider all the previously mentioned cost factors. Below, you’ll find a comparison chart of various Medicare Advantage HMOs in some of the major cities across the United States.