Medicare Advantage HMO Plans

An HMO plan, also known as a Health Maintenance Organization plan, is a popular type of Medicare Advantage Plan that offers comprehensive healthcare coverage to individuals enrolled in the plan. One of the distinctive features of an HMO plan is that it limits healthcare services to only those provided by health care providers, doctors, or hospitals that are part of the plan’s network. This means that individuals can only receive healthcare services from the providers in the network, except in emergency situations.

HMO plans are offered by private insurance companies, which contract with the government to provide Medicare Advantage Plans to eligible individuals. Most HMO plans include drug coverage, as well as additional benefits like lower monthly premiums, and vision, hearing, and fitness memberships.

HMO Plan Key Takeaways  

To receive healthcare coverage with an HMO plan, the policyholder must utilize healthcare providers, doctors, and hospitals that are part of the HMO’s network. If a policyholder seeks medical attention from a provider outside of the network, they will have to pay for the services in full, except in the case of a medical emergency. This means that staying in the HMO’s network is crucial to receive coverage.

In addition to staying in the HMO’s network, there are other important considerations for those enrolled in an HMO plan. One such consideration is the requirement to choose a primary care physician (PCP). The PCP will coordinate all of the policyholder’s medical needs and be the first point of contact in the event of any health-related issues. If a policyholder needs to see a specialist, such as a dermatologist, they will require a referral from their PCP to obtain an appointment.

It is important to note that an HMO plan offers no flexibility when it comes to choosing doctors and hospitals. Policyholders are required to use providers within the HMO’s network. This means that seeking services outside of the network will result in no coverage being provided.

On the positive side, an HMO plan typically offers a range of additional benefits, which can include adult day-care services, dental coverage, fitness memberships, hearing coverage, nutrition programs, over-the-counter drugs, services and support for those with chronic conditions, transportation to doctor visits, vision coverage, and wellness programs. These additional benefits can make an HMO plan an attractive option for individuals who require healthcare services and are looking to maintain overall wellness.

HMO costs

The costs of Medicare Advantage HMO plans may vary depending on the plan and your location. The costs can include a monthly premium, an annual deductible, copayments or coinsurance for medical services, and an out-of-pocket maximum. However, some plans have a monthly premium as low as 0$ and don’t require paying an annual deductible. The maximum-out of-pocket that is estimated on a federal level is 8300$. Prior to enrolling, it’s crucial to examine the details of each plan to grasp the specific costs and coverage.



Compared to HMO plans, PPO (Preferred Provider Organization) plans offer more flexibility to their beneficiaries. While staying within the network of healthcare providers, doctors, and hospitals is typically required to receive coverage under an HMO plan, PPO plans allow beneficiaries to access services outside of the network, albeit at higher costs. This means that with a PPO plan, you have more freedom to choose where you receive medical care.

Unlike HMO plans, most PPO plans do not require beneficiaries to choose a primary care doctor. This means that you are free to visit any hospital or doctor that you choose, without needing to coordinate your care through a primary care physician. Additionally, referrals to see specialists are not typically required under a PPO plan. This means that if you need to see a specialist, you can do so without first obtaining a referral from a primary care physician.

It is important to note that while there are differences between HMO and PPO plans, all Medicare Advantage plans must cover the basic benefits of Original Medicare Parts A and B. This means that you can expect to receive coverage for hospital stays, doctor visits, and other healthcare services regardless of which type of Medicare Advantage plan you choose.

Is it an HMO Good Option?


A Medicare beneficiary who is comfortable with having a single doctor overseeing all their medical needs may find an HMO plan to be advantageous. On the other hand, a PPO plan would be a more suitable option for those seeking greater flexibility in choosing doctors and hospitals both within and outside the network. It is still important to select a plan that aligns with one’s financial means to avoid incurring out-of-pocket expenses. In the case of HMO plans, it is essential to confirm the acceptance of the plan by nearby hospitals and doctors before enrolling, as going out-of-network may result in full payment by the beneficiary.

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