Most people know about Medicare and its different parts. But learning about Medicare can be complex. Medicare Part C, or Medicare Advantage, has its subparts, rules, and benefits. No one wants to be sick in hospital, but sometimes that can’t be helped. During these times, you are glad to have health insurance and, specifically, health insurance for Medicare beneficiaries.
Not all health insurance providers offer HMOs or insurance for seniors, however. You must diligently research your options when selecting a Medicare Advantage Plan. In this post, we’ll be talking about a Medicare Advantage plan called Health Maintenance Organization, what it is, what it covers, how it compares against other plans and more.
What Is A Health Maintenance Organization (HMO)?
A Health Maintenance Organization is a type of Medicare Advantage plan offered by private insurance companies. Like all Medicare Advantage plans, HMOs must follow certain guidelines set by the Centers for Medicare and Medicaid Services (CMS).
An HMO plan will typically have a network of doctors, specialists, and hospitals that you can use. You will likely need to choose a primary care physician (PCP) who will coordinate your care. You may need a referral from your PCP to see a specialist.
How Does A Health Maintenance Organization (HMO) Work?
Since the patient pays a fixed amount each month regardless of how often they visit a physician, an HMO may be less expensive than an indemnity plan from another company. However, if you use your insurance less often than the average person, or if you have chronic medical conditions requiring regular visits to specialists and pharmacies outside of your network, you could end up paying more for coverage through an HMO than another type of health plan.
What Does an HMO Medicare Cover?
An HMO plan will cover the same things that original Medicare covers– Part A and Part B. This includes things like:
- Inpatient care
- Outpatient care
- Emergency services
- Preventive services
Some HMO plans may also offer coverage for prescription drugs (Part D). And some plans may offer extra benefits that original Medicare doesn’t cover, like vision or dental. Some plans also cover outpatient rehabilitation services, which include physical therapy, speech-language pathology, and occupational therapy.
Rules Governing HMO Subscribers
- The subscriber may only see doctors and other healthcare providers in the company’s network.
- The subscriber must pay any co-payments, co-insurance, or deductibles required by their plan before receiving any services from a healthcare provider.
- If the subscriber does not follow one of these rules, they will be charged an additional fee for each violation.
Exemptions to the HMO Rules
The following are exempt from the HMO rules:
When You Have A Medical Emergency
You can go to any hospital or doctor for treatment when you have a medical emergency. The insurance company will pay for the services. If your plan does not cover the service, the insurance company will seek reimbursement from you. In this case, it is important to keep all records of what transpired and what was charged.
When The Hmo Does Not Have A Provider For The Service You Need
If your doctor is no longer in the network but has no comparable replacement, you are exempt from paying any out-of-network charges. This may be the case if your doctor retired or moved out of state and there was no one else in the HMO network with similar qualifications. This also applies if your doctor left his practice because he was moving out of state or retired but did not transfer his patients to another doctor in the same practice.
When You Are Getting Complex Medication And Treatment
You might need medical care if you have a chronic condition, like diabetes or heart disease. This can be hard to manage if you’re on an HMO plan. If you can’t get the care you need under the plan, the plan must let you change to a different one. The new plan may cost more than the old one. But if it helps you get the right care for your condition, then it could be worth it.
When it comes to serious conditions like cancer, heart disease, and diabetes, there’s no reason why your health coverage should limit your access to care or make it harder for doctors to coordinate their efforts. These plans have special rules about switching when someone needs complex medical treatment.
What Is The Role Of The Primary Care Physician PCP?
Most health insurance plans require insured individuals to choose a primary care physician (PCP). The role of the PCP is to coordinate care and serve as a point of contact for the patient. The plan may also require that the insured individual receive medical services from their PCP to receive benefits.
What Is A Primary Care Physician?
A primary care physician (PCP) is a licensed doctor who provides basic health services, such as physical exams, diagnosis, and treatment of common illnesses and injuries. They can also provide preventive care, which helps prevent illness or injury before it occurs. A PCP can be any licensed physician who provides care to patients without a referral from another physician or specialist.
HMO VS PPO Preferred Provider Organization
The main difference between a PPO and an HMO or EPO is that in a PPO, your insurance company will reimburse you for services you get from doctors outside of the network, but only if you have a referral from your primary care doctor. You can’t go to specialists in an HMO unless your primary care doctor refers you to one.
HMOs are more restrictive than PPOs regarding where you can get care, but they tend to lower out-of-pocket enrollees’ costs. The downside is that you may have to wait longer for appointments with specialists and other types of care. The main focus an agent can give is to advise you on which is the best option for you to choose when it comes to choosing between these two covers.
HMO Vs. POS Point-of-Service
It’s important to note that there is another type of Medicare Advantage plan called a POS, or point-of-service, plan. POS plans are similar to HMO plans in that they also have networks of doctors and hospitals. However, POS plans are more flexible than HMOs. Some key differences are:
- With an HMO plan, you will likely need to choose a primary care physician who will coordinate your care. With a POS plan, you can see any doctor in or out of the network, but you’ll pay more if you see someone out-of-network.
- HMO plans typically don’t require referrals to see specialists. POS plans usually require referrals, but you can see specialists out-of-network without a referral (although you’ll pay more).
What are the Advantages of HMOs?
- HMOs (health maintenance organizations) have several advantages over traditional health insurance:
- They offer lower out-of-pocket costs. The annual deductible and copays are often lower than those of other plans.
- You can choose from a wide range of doctors, hospitals, and providers within the HMO’s network. You may also get better access to specialists or other types of care than you would with some other types of insurance coverage.
- You’ll pay less for prescription drugs if you use in-network pharmacies. And many HMOs cover most prescription drugs without requiring you to reach a certain deductible level first.
- HMO plans don’t cover out-of-network services unless necessary, saving you money in the long run compared with PPOs (preferred provider organizations) or POS plans (point-of-service).
What are the Disadvantages of HMOs?
There are a few disadvantages of HMO plans to be aware of:
- You may have to pay more if you see a doctor out-of-network.
- You may need a referral from your primary care physician to see a specialist.
- HMO plans typically have smaller networks than other types of Medicare Advantage plans. This means there may be fewer doctors and hospitals to choose from.
In some cases, providers may require patients to use their transportation or pay for transportation services if they’re not satisfied with the level of care provided by the HMO. Most insurance plans don’t cover this cost unless specifically mentioned in your policy or contract with the provider.
Consult With Us About Your Plan
If you’re still trying to decide on a Medicare Advantage plan, our Nesso Senior Benefits specialists can help you. We’ll provide all the necessary information and discuss which plan works best for your needs.
At Nesso Group, we are here to help you through the maze and get the best price from a company that fits your needs and well-being. Get in touch with us to learn more about our services and how we can help you.
