What’s an HMO Plan?
A Health Maintenance Organization (HMO) is a type of Medicare Advantage Plan (Part C) offered by private insurance companies approved by Medicare.
With an HMO, you generally must get your care and services from doctors, hospitals, and other providers that are part of the plan’s network.
Emergency care, urgent care while traveling, and temporary kidney care (dialysis) outside of your area are usually still covered.
Common Questions About HMOs
Do HMO Plans Have Monthly Costs?
Yes. Most HMO plans charge a monthly premium in addition to your Medicare Part B (Medical Insurance) premium.
Are Prescription Drugs Covered?
Usually. Most HMO plans include drug coverage (Part D).
If having drug coverage is important to you, make sure to join a plan that offers it. If your HMO doesn’t include drug coverage, you cannot enroll in a separate Medicare drug plan.
Can I See Any Doctor or Hospital?
Not always. With an HMO, you generally must use doctors, hospitals, and other providers that are part of the plan’s network.
Emergency care, urgent care when you’re out of the area, or dialysis outside your area are still covered.
Some HMO plans, called HMOPOS (Point-of-Service), may let you get certain services outside of the network for a higher cost.
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Do I Need a Primary Care Doctor?
In most HMO plans, yes. You’ll choose a primary care doctor to coordinate your care.
Do I Need a Referral to See a Specialist?
In most cases, yes. You usually need a referral from your primary care doctor to see a specialist.
However, some services like yearly mammograms do not require a referral.
Important Things to Know
If you get care outside of the plan’s network, you may have to pay the full cost of the service.
If your plan gives prior approval for a treatment, that approval stays valid for as long as the treatment is medically necessary.
If you are in treatment and switch to a new plan, your new plan must honor your treatment for at least 90 days before requiring a new approval.
If your doctor or provider leaves the plan, the plan will notify you, and you can choose another provider in the network.
HMO plans cannot charge more than Original Medicare for certain services such as chemotherapy, dialysis, and skilled nursing facility care.
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We do not offer every plan available in your area. Currently, we represent [8] organizations which offer 8000 products in your area. Please contact Medicare.gov, 1-800-MEDICARE or your local State Health Insurance Program (SHIP) to get information on all of your options. Senior Healthcare Advisors,LLC., in California – SCH Insurance Agency represents Medicare Advantage [HMO, PPO, and PFFS] organizations and stand-alone PDP prescription drug plans that have a Medicare contract. Members may receive a monthly or quarterly allowance in the form of a benefits prepaid card to pay for a wide range of approved healthy groceries and utilities. Unused amounts will expire at the end of the month or quarter. Enrollment depends on the plan’s contract renewal. Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply. Senior Healthcare Advisors, LLC., in California – SCH Insurance Agency is not connected/endorsed by a government entity. You also agree to the Terms and Privacy The benefits mentioned are part of a special supplemental program for the chronically ill. Not all members qualify. The benefits mentioned are Special Supplemental Benefits for the Chronically Ill (SSBCI). You may qualify for SSBCI if you have a high risk for hospitalization and require intensive care coordination to manage chronic conditions such as Chronic Kidney Diseases, Chronic Lung Disorders, Cardiovascular Disorders, Chronic Heart Failure, or Diabetes. For a full list of chronic conditions or to learn more about other eligibility requirements needed to qualify for SSBCI benefits, please refer to Chapter 4 in the plan’s Evidence of Coverage. Part B Premium giveback is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Enrollment in a plan may be limited to certain times of the year unless you qualify for a Special Enrollment Period or you are in your Medicare Initial Enrollment Period.