• Medicare Advantage HMOs are popular options for additional coverage not offered by original Medicare.
  • In a Medicare Advantage HMO plan, services are limited to to in-network providers.
  • There are many different Medicare Advantage HMO plans to choose from in each state.
  • To enroll in a Medicare Advantage HMO plan, you must already be enrolled in original Medicare.

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 coverage 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.

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.

All Medicare Advantage HMO plans must cover at least:

Most Medicare Advantage HMO plans also include:

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.

So, how exactly do Medicare Advantage HMOs work? What happens if you need out-of-network emergency medical care? Do specialist visits require a referral?

Here are some commonly asked questions about Medicare Advantage HMOs.

How do Medicare Advantage HMOs work?

Medicare Advantage HMO plans rely on services from in-network healthcare providers, hospitals, and other providers. If you choose to use services from out-of-network providers, you might be charged more or the full cost of 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.

Can I keep my doctor?

If your doctor is part of the plan network, you will be able to keep visiting them for services. However, if they are outside of the network, you will either need to enroll in an HMO-POS plan or choose a different primary care physician (PCP) to avoid paying out-of-pocket costs.

A PCP is a family medicine doctor, nurse practitioner, physician assistant, internist, pediatrician, or geriatrician. PCPs treat a wide range of health issues and can help coordinate your medical treatment with various specialists.

Do I need a referral to see a specialist?

With a Medicare Advantage HMO plan, most specialist visits require a referral from your PCP. However, certain preventative visits, such as screening mammograms, do not require specialist referral.

Do they cover prescription drugs?

Each Medicare Advantage HMO plan stipulates what type of coverage it offers in addition to Medicare parts A and B. However, most Medicare Advantage HMO plans cover prescription drugs. If you require prescription drug coverage, make sure it’s included in the plan you select.

Do I have to go to a medical center for my services or prescription drugs?

With a Medicare Advantage HMO, you can visit any office, medical center, or pharmacy that is accepted in your plan’s network.

How do Medicare Advantage HMOs compare to original Medicare?

There are some key differences to consider when choosing between Medicare Advantage HMO and original Medicare. Here are some of the ways that the two types of plans differ in their coverage and costs.

Medicare Part A coverageMedicare Part B coverageMedicare Part D coverageMedigap plan available Additional coverage options Out-of-state careCosts Out-of-pocket max
Medicare Advantage HMOs yes yes usually included no yes emergencies only original costs + plan costs yes
Original Medicare yes yes can add on yes no yes original costs only no

Before you choose a Medicare plan, you’ll first want to figure out your personal needs. You can research plans that cover those needs.

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. In comparing rates with Medicare.gov’s find a Medicare plan tool, 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.

Plan name Location Monthly premium Health deductible Prescription drug deductible Doctor’s visit copays In-network out-of-pocket max
Aetna Medicare Select Plan (HMO)Los Angeles, CA $0 $0 $0 PCP: $0, specialist: $0 $2,000
Kaiser Kaiser Permanente Medicare Advantage Key (HMO) Seattle, WA $0 $0 $100 PCP: $10, specialist: $50$6,600
Cigna Preferred Medicare (HMO)Dallas, TX $0 $0 $190PCP: $0, specialist: $25 $4,200
Humana Gold Plus H5619-049 (HMO) Indianapolis, IN $0 $0 $0 PCP: $0, specialist: $35 $3,900
AARP Medicare Advantage Plan 1 (HMO) Nashville, TN $0 $0 $0 PCP: $0, specialist: $30 $5,900
CareFirst BlueCross BlueShield Advantage Core (HMO) Baltimore, MD $35 $0 $0 PCP: $5, specialist: $50 $7,550

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

Pros 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.

Cons of Medicare Advantage HMOs

  • There is less provider flexibility with HMOs compared with other Medicare Advantage plans. You will be required to choose a 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.
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  • Medicare Advantage HMOs are a popular option for those who choose to enroll in Medicare Advantage.
  • HMO plans provide a more consistent quality of care by relying on in-network providers for services.
  • There are many options for Medicare Advantage HMO plans in each state, including plans with $0 premiums, no deductibles, and low copayments.
  • When searching for the best Medicare Advantage plan for your needs, make sure you consider your own personal and financial situation when comparing plans.

This article was updated on October 13, 2020 to reflect 2021 Medicare information.

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