Medicare Advantage HMO Plans
Health Maintenance Organization plans deliver comprehensive coverage at lower costs through a trusted network of doctors, specialists, and hospitals near you.
What Is a Medicare Advantage HMO?
A Health Maintenance Organization (HMO) is the most common type of Medicare Advantage plan. HMO plans build a network of local doctors, specialists, hospitals, and other healthcare providers who have agreed to provide services at negotiated rates. In exchange for using this network, you benefit from significantly lower out-of-pocket costs compared to other plan types.
With an HMO plan, you'll choose a primary care physician (PCP) who becomes your main point of contact for healthcare. Your PCP coordinates your care and provides referrals when you need to see a specialist. This coordinated approach helps ensure that your doctors communicate with one another and that your treatment is well-managed.
HMO plans generally do not cover care received outside of the plan's network, except in emergencies or urgent care situations. This is an important consideration when choosing between an HMO and a PPO, especially if you travel often or see providers in multiple areas.
How an HMO Plan Works
Choose a Primary Care Physician
Select a PCP from the plan's network who will manage your overall health, order tests, prescribe medications, and coordinate referrals to specialists when needed.
Get Referrals for Specialists
When you need to see a specialist, your PCP will provide a referral. This ensures proper coordination and that the specialist visit is covered by your plan at the lowest cost.
Stay In-Network for Coverage
Use doctors, hospitals, and facilities within the plan's network for covered services. Emergency and urgent care are always covered, even when you're traveling outside the service area.
Benefits of HMO Plans
Lower Out-of-Pocket Costs
HMO plans typically feature lower premiums, copays, and coinsurance compared to PPO and other plan types, keeping more money in your pocket.
Coordinated Care
Your primary care physician (PCP) coordinates all of your care, ensuring your specialists, tests, and treatments are properly managed.
$0 Premium Options
Many HMO plans are available with $0 monthly premiums beyond your Part B premium, making them an affordable choice for budget-conscious beneficiaries.
Prescription Drug Coverage
Most HMO plans include integrated Part D drug coverage with their own pharmacy networks and formularies, eliminating the need for a separate drug plan.
Preventive Care Included
All HMO plans cover preventive services like annual wellness visits, screenings, and vaccinations at no additional cost to you.
Extra Benefits
Enjoy additional benefits that Original Medicare doesn't cover, including dental cleanings, eye exams, hearing aids, fitness memberships, and more.
Understanding Referrals and Network Rules
One of the most common questions about HMO plans is how referrals work. Here is what you need to know:
- Referral requirement: Most HMO plans require a referral from your PCP before you can see a specialist. Your PCP submits the referral, and you can then schedule your specialist appointment.
- Exceptions: You typically do not need a referral for annual wellness visits, women's health services, or emergency and urgent care.
- Out-of-network care: Services from out-of-network providers are generally not covered except for emergencies, urgent care, or out-of-area dialysis.
- Prior authorization: Some services, tests, or procedures may require advance approval from the plan before they are performed.
- Point-of-Service option: Some HMO plans (HMO-POS) allow limited out-of-network coverage at a higher cost, offering a middle ground between HMO and PPO flexibility.
Is an HMO Plan Right for You?
An HMO plan is often the best fit for people who want to keep healthcare costs as low as possible and are comfortable using a local provider network. Consider an HMO if:
- You want the lowest possible premiums, copays, and coinsurance.
- You prefer having a primary care physician who coordinates all of your healthcare needs.
- Your preferred doctors and hospital are already part of the plan's network in your area.
- You primarily receive care close to home and don't need frequent out-of-network access.
- You value a structured, well-coordinated approach to managing your health.
At MAC Insurance, we'll verify that your current doctors are in-network and help you understand the referral process so there are no surprises when you need care.
Explore HMO Plans in Your Area
Let our licensed agents help you compare HMO plans, verify your doctors are in-network, and find coverage that keeps your costs low — all at no charge to you.