Medicare Advantage comes in four different types: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Fee-For-Service (PFFO), and Special Needs Plan (SNP).
Medicare Advantage Health Maintenance Organization (HMO) plans are offered by private insurance companies and are a part of the Medicare Part C plan, also known as Medicare Advantage. With HMO plans you have a network of healthcare providers, doctors, and hospitals. You will most likely have to choose a primary care physician and this doctor will have to be the one who refers you to see a specialist.
You generally must get your care and services from doctors, other healthcare providers, and hospitals in the plan’s network with the exception of urgent situations and emergency situations.
HMO plan eligibility
If you are eligible for Medicare, you are automatically eligible for Medicare Advantage HMO plans. You can qualify for Medicare coverage at 65 if you are a US citizen or a permanent resident and you have lived in the USA continuously for at least five years.
If you are under 65, you can qualify if you meet these criteria:
- You have End-stage renal disease (ESRD).
- You have Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease).
- You are permanently disabled and have been receiving Social Security disability income benefits for 24 months.
To apply for Medicare Advantage HMO plans it is important to keep in mind specific times in which you can enroll in a Medicare Advantage plan:
Initial Coverage election period – A seven-month period that starts three months before the month you turn 65 and ends three months after the month you turn 65.
Annual election period – Also known as open enrollment or AEP, the annual election period for Medicare Advantage is October 15 through December 7 every year.
Medicare Advantage Open Enrollment Period – During this open enrollment period, you are able to change from one Advantage plan to another of the same or lesser quality, or drop it to return to Original Medicare.
Special Election Period – There are several things that can trigger a special election period. Since they are unique to every individual, it is best to speak to a licensed Medicare insurance agent to find out if you qualify for a special election period. However, there are a few common instances we can talk about. A few common cases in which a Special Election Period could be triggered are:
- Moving outside your Medicare Advantage Plan’s service area
- Qualifying for extra help
- Moving into a nursing home
- Provider`s termination of current Medicare Advantage plan
During this time you can make changes to your Advantage plan or return back to Original Medicare.
HMO Plans Coverage
Part C plans are generally required to provide the same benefits as Parts A and B. Those are inpatient hospital care, hospice, skilled nursing facility, lab tests, home health care, surgery, outpatient care, medical equipment, and some preventative services. Advantage plans provide additional benefits which depend on the provider and the specific plan of your choosing.
HMO Plans cover immunizations, annual check-ups, and flu shots, as well as certain tests and screenings.
However, they also have additional benefits not covered by Original Medicare – Parts A and B like an out-of-pocket maximum limit and:
- Adult day-care services
- Fitness memberships
- Nutrition programs
- Prescription drugs
- Over-the-counter drugs
- Services and support for those with chronic conditions
- Transportation to doctor visits
- Wellness programs
Check in with your plan provider to see which benefits you are eligible for. Other than your provider’s specific conditions, benefits will also depend on your area.
HMO Plans costs
Unless they are premium-free plans, Medicare Advantage HMO plans may have their own monthly premium. They generally have their ownin-network deductible amounts, which can start as low as $0. HMO plans have different copayment amounts for primary care doctor and specialist visits.
You will usually pay 20% for the medical services you receive if the deductible terms are fulfilled.
Are Prescription Drug Costs Covered in HMO Plans?
In most cases, prescription drugs (Part D) are covered in HMO Plans but you need to ask your plan’s provider. It is possible to join an HMO Plan that covers prescription drug costs. You will not be able to join a separate Medicare drug plan once you decide to join an HMO plan that doesn’t cover drug costs, so decide carefully.
The Difference Between HMO and PPO Medicare Advantage plans?
Medicare Advantage HMO and PPO are generally similar but some key differences are:
- PPO plans allow you to see doctors outside the plan network, even though it might cost you more in coinsurance or copayments. With an HMO, you can’t go out-of-network
- With a PPO, you don’t have to choose a primary care provider, but you do with an HMO.
- PPOs don’t require a referral to see a specialist. With an HMO you are obliged to get one.
- Because of their flexibility, PPO plans typically have a higher premium.