Medicare health maintenance organization (HMO) plans are a type of Medicare Advantage plan. The plans are offered by private insurance companies, with varied coverage and costs. Show In this article, we discuss Medicare Advantage, look at the HMO plans, and examine how they compare with original Medicare. We also look at eligibility, enrollment, and costs.
Share on PinterestMedicare Advantage plans combine the benefits of parts A and B and may offer prescription drug coverage. The Balanced Budget Act of 1997 added a new Part C to Medicare called the Medicare+choice program. It included various coordinated healthcare plans, including health maintenance organizations (HMOs). The Medicare+choice program is now known as Medicare Advantage. In addition to plans such as the health maintenance organization (HMO) and HMO point-of-service (HMOPOS) plans, the program offers:
Advantage healthcare plans are offered by private companies that must follow Medicare rules and offer the same benefits as original Medicare (Part A and Part B). Many also offer prescription drug coverage. One type of Advantage healthcare plan is the health maintenance organization (HMO) plan. It limits healthcare to providers within the plan’s network. The focus of HMO plans is on prevention and wellness. They provide coordinated care, often using care managers within the company or a primary care doctor. Usually, the doctors and other service providers must either contract with, or work for, the company offering the HMP plan. SpecificsHMO plans have certain limitations and conditions:
This online tool can help a person compare HMO plans in their area. To access the plan a person uses the benefit card from the HMO and not their Medicare card. The list of healthcare providers in an HMO plan’s network may be limited in number and specialty. A person may wish to consider an HMO plan with point-of-service (POS) options. A POS plan is a hybrid of an HMO and a preferred provider organization (PPO) plan, with these differences:
When a person takes the HMO-POS option, they may have higher out-of-pocket costs. They may also have to pay most of the cost unless they have a referral from a doctor to the out-of-network provider. If a person has been referred, the HMO-POS plan will cover the services. In addition, if a person goes to an out-of-network healthcare provider, they have to file the paperwork with their HMO-POS company. A person has to pay the provider, and then wait for reimbursement for the allowable charges. Medicare Advantage plans combine the benefits of original Medicare (Part A and Part B). Medicare Part A is hospital insurance and provides coverage for hospital, skilled nursing, and hospice care. Medicare Part B is medical insurance and provides coverage for the diagnosis and treatment of medical conditions, and some preventive services such as flu shots or cancer screening. Medicare Advantage plans must provide coverage for the same benefits offered through original Medicare. However, Advantage HMOs may offer additional benefits, such as:
In addition, if a person wants prescription drug coverage, Medicare Part D, they can get it through the HMO plan. However, a person cannot have Medicare Part D and an Advantage HMO plan at the same time. A person must be enrolled in original Medicare to be eligible for an Advantage plan. For the HMO plan, a person must also live in the plan’s service area. The Centers for Medicare and Medicaid Services (CMS) added two special enrollment periods for a person enrolled in an Advantage plan who has a consistent record of poor performance, or is having financial problems and the assets are held by a third party called receivership. In addition, there are other eligibility requirements for a person with end stage renal disease (ESRD). In 2020, people with ESRD are only eligible for an HMO Advantage plan if they enroll in a special needs plan (SNP), or previously enrolled in an HMO before the ESRD diagnosis. From January 1, 2021, changes in the regulations mean that a person with ESRD can enroll in an Advantage plan during any valid enrollment period. People can enroll in a Medicare Advantage plan, including a HMO plan, during several enrollment periods:
A person enrolled in an Advantage HMO plan must generally pay the premium for Medicare Part B, and a plan premium. However, some HMO plans help pay a percentage of the Medicare Part B premium. HMOs usually have the lowest out-of-pocket costs. These can include premiums, deductibles, coinsurance, and copays.
All HMO plans have an out-of-pocket maximum, although the amounts vary among plans. A person can check plan costs and other details using this online tool. Medicare Advantage plans combine the benefits of original Medicare (Part A and Part B), and may offer prescription drug coverage. Among several other Advantage plans, a HMO plan generally has lower out-of-pocket expenses. Healthcare is given by in-network providers, although emergency services can be covered out-of-network. The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance. Which type of MA plan is an HMO plan that also covers some benefits outA variation on the Medicare Advantage HMO, HMOPOS plans add more flexibility to how you access care and coverage. You can usually go outside the plan's HMO network without referrals. You might pay a higher cost-share for out-of-network services. A Medicare Advantage POS plan may be more expensive than an HMO plan.
What do HMO plans require of the enrollee?Most HMO plans require an enrollee to obtain medically necessary covered services through the HMO's delivery Network. An enrollee may receive care outside of the HMO's network during emergencies or instances in which necessary covered services are not available through the HMO's delivery Network.
Which of the following defines a Medicare Advantage MA plan?A Medicare Advantage (MA) plan is a type of health plan offered by a private company that contracts with Medicare to provide you with all your Medicare Parts A and B benefits. MA plans include health maintenance organizations, preferred provider organizations, private fee-for-service plans, and Special Needs Plans.
Which type of MA plan is an HMO?MA HMO plans are managed care plans. A primary care physician works with each plan member to manage their medical care. All specialty services must be authorized by the plan or contracting medical group. Medicare Advantage plans that include Part D prescription drug coverage are called MAPD plans.
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