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Medicare HMO Plans

Over ten million seniors choose to enroll in Part C Medicare Advantage programs, which allow them to seek medical coverage from a Medicare-approved private insurance company.  Medicare-eligible beneficiaries have many plans and services to choose from. One of these options is care through Health Maintenance Organization (HMO) plans, health care plans which opt for a managed care approach rather than the traditional Medicare fee-for-service program. HMO plans must offer the same benefits as Part A and Part B coverage.  If you opt to enroll in a Medicare Advantage HMO plan, you should consider cancelling your supplementary insurance because Medigap coverage will not work if you are enrolled in an HMO. 

Medicare HMOs are contracted by the government to provide private insurance options for Medicare beneficiaries as an alternative to the original program. HMO plans focus on managed care, emphasizing on the importance of preventative health services. You must continue to pay your Part B premiums to ensure full medical coverage. HMO plans simplify payment systems and also cut down on paperwork. You may have to pay copayments for doctor visits, and generally, you would have very low or $0 monthly premiums, depending on the HMO plan you choose.  Many HMO plans offer additional benefits not typically offered by traditional Medicare, including dental, vision, and prescription drug coverage. If you opt to enroll in an HMO plan, you may save money while receiving these additional benefits.

To lower costs for beneficiaries, HMOs use networks of physicians, specialists, and hospitals. You must select a primary care physician from the HMO’s network. Your HMO Advantage plan will pay for health services that are pre-approved by your primary care doctor. Primary care physician referrals are normally required for visits to specialists and hospitals, except in the event of necessary emergency care. Some HMOs offer point of service (POS) options, which allow you to see out of network physicians at an additional cost to you. You must also use your HMO’s insurance card instead of your Medicare card for any of your health needs. 

To enroll in an HMO, you must qualify for Medicare Part A and B benefits and live in the designated service area of that HMO. Unless you have been diagnosed with end stage renal disease, you can enroll in a plan if you have pre-existing conditions. Again, you must continue to pay your Part B premiums even if your HMO has $0 premium. You can enroll in any HMO when you first qualify for Medicare benefits during your initial enrollment period or during the Annual Enrollment from November 15th to December 31st (Advantage plans and Part D coverage). A special enrollment period may be available for those who qualify. You have the right to cancel your HMO policy at any time before the effective date so long as your enrollment is incomplete.

When selecting the HMO Advantage plan that is right for you, you must consider your own health needs as well as the benefits and costs associated with the program. By understanding both your own personal health as well as the HMO’s policy, you can find an HMO plan that is tailored to your needs.