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HMO Plans

Health Maintenance Organization (HMO) Plans are a type of Medicare Advantage Plan. The coverage provided by HMO Plans is network-based, with some exceptions, such as emergency and urgent care.


HMO Plans have relatively strict network coverage. Before enrolling in an HMO Plan, check the network and make sure you’re satisfied with the coverage provided. HMO Plans are a great way to gain access to medical professionals, but be sure you’re comfortable with the network allowances.

Medicare HMO Plans - 3 Things You Need To Know! - Video Transcript >

Medicare HMO Plans - 3 Things You Need To Know!

Sean Brady here with My Healthcare Direct. Today we're going to be talking about Medicare Advantage HMO plans and what it means to you. My Healthcare

Direct is an independent insurance agency. We work with every insurance carrier most likely in your area, in your state. We work with up to about 25 states in the continental US right now, and our goal is to help as many seniors, as possible: educate them on what Medicare is, what it is not, and that's why we're here.

So let's dive in. Today we're gonna learn about Medicare Advantage HMOs. Now, if you like what you see today, go ahead and subscribe to the page. We're going to be releasing more content. You can click the bell, and if you like what you see, you'll get notified as more content is put out weekly. And of course, if you have any questions, my team and I are here, ready to help you. So, please shoot me an email, give us a call! Either myself or someone from our team will be more than happy to help you.

All right, so let's dive in.

Medicare Advantage HMO plans, what do we need to know?

What does HMO stand for?

First thing: What is an HMO? What does it stand for? HMO stands for Health Maintenance Organization. It's a network of doctors and hospitals that you would need to stay within. That's the first thing to understand. 

The second thing - and kind of the real difference why it sets itself apart from a PPO plan - would be your primary care physician or your PCP. 

With an HMO plan you have to select your PCP and you have to stick with that PCP. I believe you can change maybe up to once a month if you really needed to, but generally speaking you're kind of locked in for the year. You know you want to kind of stick with that one PCP. That's kind of one of the main differences.

With original Medicare you you have a little bit more freedom as far as the doctors and hospitals that accept it. What I mean by that is: Most doctors, hospitals throughout the United States are going to accept original Medicare, it's something like 90, 95%. I mean it's very high. 

With an HMO plan, it all depends on where you are. Let's say, in your particular state you have an HMO plan. The network for that HMO plan is usually tied to your local area.

The reason why I say that is, once you get outside your local area, that's when some people run into some issues. as far as doctors and hospitals possibly not accepting your HMO plan. So, that's the one thing you want to make sure - you look up your doctor, hospital, if they're important to you, with your agent and make sure you get that question answered: Are they in network, are they not? Because that's a big factor there.

You're going to have a lot of benefits that they add on. Some people might say “it's kind of bells and whistles to kind of lure you in” and that sort of thing, but  they're good benefits, a lot of them, so you want to take a look at those and see what they have to offer.

What are the benefits?

  • Prescription drug coverage is included in the plan.
  • You're going to have dental benefits with some of them.
  • You're also going to have vision and potentially hearing. 

So ask your agent about that, and we can kind of go over that. Some of them are zero cost. So something to consider when you're looking at all your options.

How much do HMO plans cost?

The first thing to understand is you have your Part B premium alright, so whether you go with a Medicare supplement, whether you stay with original Medicare, or whether you choose to go with a Plan C, a Medicare Advantage plan, in this case

an HMO plan, you are all still going to need to be responsible for that 148 dollars and 50 cents Part B premium, and that's for 2021.

148 dollars and 50 cents, so that's the first thing to understand as far as cost.

Many of the plans are actually zero premium, and you might be scratching your head and say: “Well, Sean, nothing's for free, I don't understand.”

Well, Part C or a Medicare Advantage plan, they have so much robust benefits that they add on, it's very enticing, and so that's something you're going to definitely want to take a look at.

If you want to sign up for an HMO plan, there's positives and negatives.  So, obviously the positive is: Maybe it's going to be zero premium, maybe you have dental, vision, hearing benefits included.

But what are the drawbacks? Well, the network may be the one thing that you have to take a look at. If you have a bunch of doctors and hospitals that you see, and if you travel often out of state - okay, that's one right there, that's going to be something you're going to want to take a look at and weigh: “Is it worth getting a network that I can't see a lot of the doctors that I normally see, or when I travel I can't see the doctors that I need to?” 

Maybe if you're a snow bird - for those type of situations, that's where I would maybe recommend more of a Medicare supplement, stay with original Medicare, keep that strong network, but if you don't see a lot of doctors and hospitals regularly and you're pretty healthy and you just stick in your kind of local area and you kind of just do your thing once a year, an HMO plan might be a good fit for you. 

You get to save money monthly.
You get other benefits like dental, vision, hearing, things like that.
Some of them have gym memberships, “Silver Sneakers”, so just some things to think about.
And they'll also have it spelled out what the benefits are. It’s all listed, so there's no confusion.

The other thing to consider is your maximum out of pocket. For 2021 it's gonna be 7,550 USD, so that's another thing to take into consideration, and we already kind of went over a little bit about the cost and the network.

HMO Plans Referrals

The main thing to consider is the HMO is going to be more restrictive as far as the network and which doctors and hospitals you can see. You're also going to need a referral and I'm not sure if I mentioned this earlier, but you're going to need a referral each time you see a specialist. That's another kind of drawback some people are not so comfortable with. That means every time you want to go see your cardiologist or your urologist or whoever it is, you first have to check in with your primary care physician, get that referral from them, and then you go to your specialist. So it can be a little bit of a pain for some folks, but

I just want to explain how that works.  There's probably a lot more questions that you have, that's why we're here.0 Go ahead and give us a call. Give me a call, shoot me an email. My team and I are here to help you, and we look forward to talking with you.

Prescription drugs

Just like PPO Plans, most HMO options offer prescription drug coverage. Remember, if enrolled in Medicare Advantage, you cannot enroll in Part D to get medication coverage.

Primary care doctor

Most HMO Plans require their beneficiaries to choose a primary care doctor. They can help write referrals, which are needed within HMO Plans.

We can help!

Want to learn more about HMO Plans?

If you’re wanting to learn more about the options that an HMO Plan could provide you with, reach out to one of our professionals today.

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