Health Maintenance Organization (HMO) plans provide a network of healthcare providers at a lower cost than other Medicare Advantage (Part C) plans. It is one of 4 Medicare Advantage plans, the others being SNP, PPO, and PFFS plans.
The primary benefit of a Health Maintenance Organization plan is that it costs less than other types of health insurance and especially in contrast to a Preferred Provider Organization plan costs.
By enrolling in an HMO plan you have the ability to have improved access to healthcare, and a wider network of generalist and specialist physicians.
You’re eligible for an HMO plan as long as you’re enrolled in Original Medicare (Part A and Part B) first. And, like the other Advantage plans, HMO plans include all of the benefits of Original Medicare.
Most plans will also include prescription drug coverage, and various other additions depending on the insurance provider.
Medicare Advantage, or Part C plans, are insurance plans that are provided by Medicare-approved private insurance companies and are another way of getting your Medicare Part A and Part B.
These plans provide all of the Original Medicare benefits, excluding clinical trials, hospice services, and, for a temporary time, some new benefits that come from legislation or national coverage determinations.
Medicare Advantage Plans must cover all emergency and urgent care and almost all medically necessary services Original Medicare usually covers.
Most of these plans generally don’t cover medical care outside of the U.S. but some plans may offer a supplemental benefit that covers emergency and urgently needed services when traveling outside of the country.
Also, Most Medicare Advantage Plans include drug coverage (Part D). Ask the plan you choose to join if you want to make sure. In case you join an HMO plan that doesn’t provide drug coverage, you are not able to join a separate Medicare drug plan.
To conclude, there are many benefits to a Medicare Advantage plan. With a Part C plan, you may have coverage for things Original Medicare doesn’t cover such as fitness programs.
Also, some vision, hearing, and dental services might be covered as well such as routine checkups or cleanings. In case you are diagnosed with a very specific condition, a Medicare Advantage plan can tailor their benefits to help you take care of your diagnosis.
As with every plan, you should check with our Medicare advisors before you enroll to see what benefits are available to you and if you might qualify, as well as if there are any limitations and if those limitations work for you.
The main draw of Advantage plans is not, however, these additional benefits. Part C aims to lower your out-of-pocket costs for consistent healthcare under Original Medicare.
In other words, it covers things like doctor visits and checkups in exchange for a generally lower monthly premium and, as we previously mentioned, lower out-of-pocket costs.
All Advantage plans function on a network of healthcare providers, but HMO plans rely on it more than the others. This network is limited, but likely more than suitable depending on the range of care you are looking for.
Even though HMO plans can be thought of as the most restrictive ones because of the network boundaries set by the plan for individuals that purchase enroll in an HMO, they are by far the most affordable which makes them so popular.
You won’t have to worry about this network for emergency out-of-network care. However, for doctor’s visits for a specific issue or checkup, you are required to see a primary care physician and get a specialist referral for further treatment.
It is important to check if your current primary care doctor is a part of the HMO’s network. If this is not the case, you will need to choose a new doctor who is inside the network.
This means that you will only have one option for immediate treatment (unless it’s an emergency). However, most people don’t see this as an issue, especially in light of the cost. HMO plans are incredibly inexpensive, with little to no monthly premiums.
HMO, then, is a great Advantage plan, perfect for those who want some extra help with out-of-pocket costs without breaking the bank.
The most common Advantage plans are HMO and Preferred Provider Organization (PPO) plans. Special Needs Plans (SNPs) are reserved for those eligible—if you do qualify for one, you will more than likely want to choose it over any of the other options, including HMO.
Private-Fee-for-Service (PFFS) plans are a great option for those who frequently travel. However, coverage is subject to change, and it can be a difficult plan for the average person to navigate on their own. It is significantly more expensive than an HMO plan.
PFFS plans are different than Original Medicare plans or Medigap. The plan itself determines how much it will cost to get service from doctors, other health care providers, and hospitals, and how much of a financial responsibility it will be for you to pay when you get care.
That leaves us with HMO and PPO plans. Your choice will mostly depend on your budget and need for flexibility. HMO plans are cheaper, but with a more limited network and required primary physicians and referrals.
Preferred Provider Organization plans (PPO) have a wider network and no required primary physician or referrals, but at a higher cost than an HMO plan.
However, PPO plans allow you to receive care from any healthcare provider—in or out of your network which implies the collection of doctors, offices, etc. that your insurance provider has established.
In other words, a PPO plan gives you the opportunity to see any doctor or specialist, or use any hospital which is perfect for individuals who are looking for flexibility and/or travel a lot during the course of the year.
Nevertheless, we advise you to stay within your plan’s network to avoid additional costs but if you don’t mind paying a larger out-of-pocket amount, this shouldn’t be a big concern.
Both HMOs and PPOs are excellent options, and you will reduce your out-of-pocket costs no matter which one you choose.
Medicare Advantage is provided by private insurers—that means that it is up to you to seek out the best price and coverage.
But this can be impossible to do on your own. Texas Medicare Advisors helps people just like you find the coverage they need within their budget. If you’d like a consultation with one of our experts, give us a call at 512-900-3008.
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