Plans & Coverage
Medicare HMO Plans
An HMO (Health Maintenance Organization) is a type of Medicare Advantage plan that generally uses a provider network for non-emergency care. Many HMOs require referrals to see specialists, while HMO-POS plans may cover some out-of-network services. Rules, costs, and coverage vary by plan, so check the plan's Evidence of Coverage and confirm your providers before enrolling.
Pros and cons
Some HMOs have low or $0 plan premiums, set copays, or extra benefits. In most HMOs, routine non-emergency care generally must be in-network, and referrals may be required. Emergency and urgently needed care have different rules; HMO-POS plans may cover some out-of-network services. Check the specific plan's costs, referrals, and provider network.
Questions, answered
What happens if I see an out-of-network doctor on an HMO?
Routine out-of-network care generally isn't covered by an HMO, but emergency and urgently needed care are treated differently, and an HMO-POS plan may cover some out-of-network services. Check the plan's rules before receiving non-emergency care outside its network.
Do I need to choose a primary care doctor with an HMO?
Usually. Most Medicare Advantage HMOs require you to choose a primary care doctor, but plan rules can vary. Check the plan’s current materials before enrolling.
Do HMO plans require referrals to see specialists?
In most cases, yes. Some services may not need a referral, and requirements vary by plan. Confirm the referral and prior-approval rules with the plan before scheduling care.
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