Health Maintenance Organizations (HMOs)

What's an HMO?

An HMO is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. When you have an HMO, you generally must get your care and services from doctors, other health care providers, and hospitals in the plan's network, except:

Emergency care
Out-of-area urgent care
Temporary out-of-area dialysis

Some HMOs are Point-of-Service (HMOPOS) plans that may allow you to get some services out-of-network for a higher copayment or coinsurance . It’s important that you follow the plan’s rules, like getting prior approval for a certain service when the plan requires it.

Questions you may have about HMOs:

Question:	Answer:
Do these plans charge a monthly premium ?	Yes. These plans usually charge a premium, in addition to the monthly Part B (Medical Insurance) premium.
Do these plans offer Medicare drug coverage (Part D)?	Usually. Prescription drugs are covered in most HMOs. Check with the plan you’re interested in. HMOs & drug coverage If you want prescription drug coverage, you have to join an HMO that offers it. If you join an HMO plan that doesn't offer drug coverage, you can't join a separate Medicare drug plan.
Can I use any doctor or hospital that accepts Medicare for covered services?	Sometimes. You generally must get your care and services from doctors, other health care providers, and hospitals in the plan’s network (except for emergency, urgent care, or out-of-area dialysis). In an HMOPOS plan, you may be able to get some services out of network for a higher copayment or coinsurance.
Do I need to choose a primary care doctor ?	Usually. In most HMOs you need to choose a primary care doctor.
Do I have to get a referral to use a specialist?	Yes. In most cases, you have to get a referral to use a specialist in HMO Plans. Certain services, like yearly mammogram screenings, don't require a referral.
What else do I need to know?	If you get health care outside the plan's network, you may have to pay the full cost. If your plan gives you prior approval for a treatment, the approval must be valid for as long as the treatment’s medically necessary. Also, your plan can’t ask you to get additional approvals for that treatment. If you’re currently getting treatment and you switch to a new plan, you’ll have at least 90 days before the new plan can ask you to get a new prior approval for your ongoing treatment. If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another provider in the plan. Your plan can’t charge more than Original Medicare for certain services like chemotherapy, dialysis, and skilled nursing facility care. Check with the plan you’re interested in for specific information.