What is a Medicare HMO?
A Medicare HMO is a Medicare Advantage Plan with a health maintenance organization as its provider network. Most Advantage plans are network-based, but they don’t all work the same way.
When you join a Medicare HMO, you must follow rules set by the plan. There are two things that distinguish an HMO from other types of Advantage Plan networks.
- You must choose a primary care provider and get referrals from that provider to use the services of other specialists and facilities.
- You must get all of your services from the Health Maintenance Organization’s network.
At first sight, those two points are acceptable, but could pose problems in certain circumstances. You may feel frustrated later if you don’t think about these things before you join a plan.
Don’t let this happen to you
While getting referrals for every problem limits your freedom to manage your health care, the biggest problem comes when you need a provider or a specific type of procedure that isn’t offered within the HMO network.
Let’s assume for a minute that you are diagnosed with a rare form of cancer. The good news is that it has been treated in-network with some success, but the leading treatment with the highest record of success is only available at a specialty hospital that is not in your network.
You know this cutting edge treatment exists and you know the positive results are real. But you can’t go out of network to get treatment. Your Medicare HMO will not pay for it. And while you’re enrolled in the HMO, neither will Medicare.
If you had Original Medicare or Original Medicare and a supplement, you would have no problem getting the main treatment. If you’re in a Medicare PPO, you might pay a little more, go out of network, and get the best treatment. But not with the HMO.
How should you proceed?
Medicare HMOS are popular. You’ll often find more HMOS in service areas with major metropolitan areas than other types of Advantage Plan networks.
It’s tempting to join this type of plan because the cost-sharing amounts (deductibles, copays, and coinsurance) are often lower than plans with other types of networks. And these plans often have more supplemental benefits, such as dental, vision, hearing, and gym memberships, compared to other non-HMO plans.
Before you sign up for a plan, you should research the network thoroughly. No one has a crystal ball, but doing a little research before you sign up can give you a better idea of the services available. Consider your health and your family’s health history to play the And yes play. Thinking through possible scenarios could save you some frustration in the future.