HMO Plans

Medicare Advantage comes in two different types: PPO and HMO plans. 

HMO plans have a network of healthcare providers, doctors, and hospitals. 

In most cases, you will have to stay in the network and choose a primary care physician. You will also have to get a referral to see a specialist.

If you are having a medical emergency, you can go outside of the plan’s network. However, that is usually the only instance you can do so. 

In all other cases, you will have to pay for treatment out of your own pocket if you go outside the network to receive treatment.

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What do Medicare Advantage HMO plans cover?

Medicare Advantage plans cover your Part A and B benefits. So, they’ll provide Part A benefits: inpatient hospital care, skilled nursing facility care, home health care and hospice care. 

They also provide Part B’s benefits: medically necessary services and preventive services.

However, they also have additional benefits not covered by Parts A and B like an out-of-pocket maximum limit and: 

  • Adult day-care services
  • Dental
  • Fitness memberships
  • Hearing
  • Nutrition programs
  • Prescription drugs
  • Over-the-counter drugs
  • Services and supports for those with chronic conditions
  • Transportation to doctor visits
  • Vision
  • Wellness programs

However, benefits your plan offers will vary based on where you live.

How do PPO Plans and HMO Plans differ?

Both variations have a network of providers. However, HMOs do not allow you to receive care from doctors outside of the network. However, it is important to note that even though you’re allowed to receive care outside the network with a PPO, it will cost more. 

HMOs also require you to choose a primary care provider and get referrals to see specialists. PPOs do not.

Because of the added flexibility and freedom, PPOs have a higher monthly premium.