Medicare Advantage HMO

By: Edward Neeman
Published: Wednesday, July 25 2018
Last Updated: 5 years ago

What Is Medicare Advantage HMO?

A Medicare Advantage HMO is similar to what people are used to receiving from their employer. They are required to see in-network providers. This means that you will need to search your plan for in-network providers that fall into the following categories:

  • Physicians
  • Hospitals
  • Other Healthcare Providers

In order to see a specialist, you may be required to obtain a referral from your doctor, and you may need to get a medical exception for certain specialists that are considered out of network.

What Does Medicare HMO Cover?

What can be expected from Medicare Advantage HMO benefits? HMO plans provide a number of benefits. These benefits include affordability and dependability for its members.

There is some research involved in choosing an HMO, and you will need to do some research to determine which doctor, hospital, and pharmacy you will use with your HMO. Typically, you are able to receive care from providers that work within the plan's network. However, you may receive an exception for providers that are considered out-of-area for the following services:

  • Emergency Services
  • Out-of-Area Urgent Care Services
  • Out-of-Area Dialysis Providers

There are some plans available that allow you to receive out-of-network services. However, choosing providers that are considered in-network will save you a lot of money. If you are interested in being able to receive services that are out of network, consider signing up for an HMO with POS plan instead.

Are Prescription Drugs Covered?

Most Medicare Advantage HMO benefits include prescription drug coverage. However, not all of them do. Make sure to ask whether the plans you are considering include prescription drug coverage, better known as Medicare Part D. If you are extremely interested in a Medicare Advantage plan that does not include prescription drug coverage, you can pick up a Part D plan separately.

How Medicare Advantage HMO Plans Work

Medicare Advantage members who choose to receive their benefits from a Medicare HMO, you will have to choose a primary care doctor to receive the majority of your treatment from. Your primary care doctor will provide most of your care, and you will need a referral to see a specialist. If you have a medical condition that requires you to see a specialist, this will not be difficult to obtain from your primary care doctor.

Signing up for a Medicare Advantage plan will also offer more preventative care treatment than you would be provided through original Medicare. You are also less likely to have a deductible, or high out-of-pocket expenses like you would on traditional Medicare. It is important to note that if you choose an HMO Medicare Advantage plan, you will not be covered for any services provided by out of network doctors unless you have obtained a referral from your primary care physician.

Do You Need a Primary Care Physician?

Yes, a Medicare HMO will require you to choose a primary care physician if you want to receive Medicare Advantage HMO benefits.

Do You Need Referrals To See A Specialist?

While an HMO will provide you with more benefits than Original Medicare, you will still need to choose a physician that is in their network. You will need to see this doctor on a regular basis, and you will need to receive a referral from this physician to see a specialist.

Staying In Network

To receive your Medicare Advantage HMO benefits, you will need to see physicians that are considered in network. You will also need to follow the protocol that your policy outlines in order to see specialists. You will not receive your Medicare Advantage HMO benefits if you choose to see a provider that is out of network.

Medicare Advantage HMO List

There are a lot of different Medicare Advantage plans that offer HMO coverage. Each plan will offer access to a different provider list. Make sure to save your MA HMO provider list and their list of approved pharmacies in your network. This will save you a lot of hassle when it comes to choosing a doctor, choosing a specialist, and choosing a pharmacy.