The Complete Guide to HMO Plans

If you are looking for Medicare coverage, you may have come across the term HMO. But what does HMO stand for? And what do HMO plans cover? This blog post…

April 20, 2022

Written by Trey Bongiovanni

If you are looking for Medicare coverage, you may have come across the term HMO. But what does HMO stand for? And what do HMO plans cover? This blog post will explain everything you need to know about HMO plans.

We will discuss what an HMO is, what each plan covers, and how to choose the right plan for your needs. So whether you are just starting to research your Medicare options or if you are already enrolled in an HMO plan, this blog post is for you.

What’s Medicare?

Medicare is a government health insurance program for people age 65 or older, people with disabilities, and people with End-Stage Renal Disease (ESRD). There are several different parts of Medicare, and each part covers different services.

What Are The Different Parts Of Medicare?

Medicare has four parts: Part A, Part B, Part C, and Part D. Parts of Medicare can vary depending on the state you live in. Some states offer additional coverage that others don’t. It’s important to research what your state offers to get the most out of your Medicare coverage.

Part A

Part A is hospital insurance. It helps pay for inpatient care in a hospital or skilled nursing facility (not including custodial or long-term care).

Part B

Part B is medical insurance. It helps pay for doctors’ services, outpatient care, home health care, and other medical services.

Part C (Medicare Advantage)

Part C is Medicare Advantage Plans. These are private health plans that offer all the benefits of Parts A and B. Most also include prescription drug coverage (Part D). Medicare Advantage Plans can be HMOs, PPOs, or Private Fee-for-Service Plans. You must have both Parts A and B to join a Part C plan.

Part D

Part D is prescription drug coverage. It helps pay for the cost of prescription drugs. You must have both Parts A and B to join a Part D plan.

What is an HMO?

An HMO is a type of Medicare plan that offers coverage for medical care from doctors who are part of the plan’s network. With an HMO, you generally need to see a doctor in the plan’s network to receive coverage.


HMO Plans

There are three different types of HMO plans: local, regional, and national.

Local HMO Plans: A local HMO plan is a plan that only offers coverage in a specific area. If you live in a city, several local HMO plans may choose from.

Regional HMO Plans: A regional HMO plan is a plan that offers coverage in more than one state. These plans usually have a larger network of doctors and hospitals than local plans.

National HMO Plans: A national HMO plan is a plan that offers coverage nationwide. These plans have the largest network of doctors and hospitals of all the HMO plans.

What Do Hmo Plans Cover?

All HMO plans cover medical care from doctors who are in the plan’s network and some preventive services at no cost to you.

HMOs also offer prescription drug coverage. However, not all drugs are covered under every plan, so it’s important to check your plan’s formulary (the list of drugs your plan covers).

In addition, most HMOs offer vision and dental coverage.

How To Choose An HMO Plan

When choosing an HMO plan, it’s important to consider your needs and budget. Some things to consider include:

  • The size of the plan’s network of doctors and hospitals
  • The cost of the plan
  • What services are covered by the plan
  • The co-pays and co-insurance for doctor visits, hospital stays, and prescription drugs
  • Whether the plan offers coverage for vision, dental, and other services

Pros And Cons Of HMO Plans 

When looking at HMO plans, there are several things you need to know and consider before choosing which plan is best suited for you. Here are some of the most important:

HMO Plan Pros

  • HMOs often have lower premiums than other types of Medicare coverage.
  • HMOs offer comprehensive coverage, including preventive care, doctor’s visits, hospital stays, etc.
  • HMOs typically have a large network of doctors and hospitals from which members can choose.

HMO Plan Cons

  • Members may only see providers within the HMO’s network; if they need care from a provider, not in the network, they may have to pay out of pocket.
  • Some services may only be available in certain geographic areas served by the HMO.
  • HMOs may not be available in all areas of the country.

It’s important to weigh the pros and cons of HMO plans before deciding on a coverage. Speak with an insurance agent to learn more about HMO plans and find the right coverage for you.

Basic HMO Plan vs. Premium HMO Plan

There are two types of HMO plans; the basic HMO plan and the premium HMO plan. The basic HMO plan typically has a lower monthly premium than other types of Medicare coverage, but it also has more restricted coverage. The premium HMO plan offers more comprehensive coverage and typically has a higher monthly premium. 

HMO Plans VS PPO Plans

HMO plans are very different from PPO (Preferred Provider Organization) plans. Members can see any doctor or go to any hospital they want with a PPO plan, regardless of whether the provider is in the plan’s network. However, members must see providers within the HMO’s network; if they go outside of the network for care, they will have to pay out-of-pocket. 

HMO Plan VS POS Plan

HMO plans are also different from POS (Point of Service) plans. With a POS plan, members can see any doctor or go to any hospital they want, but they may have to pay more for care if they go outside the plan’s network. With an HMO plan, members must see providers within the HMO’s network and will typically not have to pay more for care if they go outside of the network. 


Primary Care Provider

Members of an HMO plan must have a primary care provider (PCP). The PCP is the doctor that members see for most of their routine health care. Members can go to any doctor they want for specialty care, but they must first get a referral from their PCP.

Special Treatment Referrals

If a member needs special treatment, such as chemotherapy or radiation therapy, they will need to get a referral from their PCP. This referral ensures that the member gets the care they need and that the plan will cover it. 

In-Network Providers

Members of an HMO plan must see providers in the plan’s network. This means that members can go to any doctor or hospital they want, but they will have to pay more for care if they go outside the network. 

In-Network Exceptions

There are a few exceptions to the rule that members must see in-network providers. If a member is traveling out of town and needs to see a doctor, they can go to any doctor they want, and the plan will cover the visit. Also, if a member needs emergency care, they can go to any hospital, and the plan will cover the visit.

Emergency Care

Members of an HMO plan can go to any hospital for emergency care. The plan will cover the care received at the hospital.

Mandatory Preauthorization

Some services may require preauthorization from the insurance company before being covered. This means that the member must contact the insurance company before receiving the service to make sure it will be covered.

Annual Physical Exam

HMOs typically require members to have an annual physical exam. During this exam, the doctor will review the member’s health history and do a physical examination. This helps the doctor catch any health problems early on and provides a baseline for future care. 

Wellness Programs

Many HMOs offer wellness programs to their members. These programs can include health education classes, screenings, and more. Participation in these programs can help members stay healthy and lower their overall health care costs.

HMO Plan Costs

The cost of an HMO plan varies depending on the insurance company and the area where you live. Typically, HMO plans have lower monthly premiums than other Medicare plans. However, members usually have to pay more for care if they go outside the network.

Copayments

Members of an HMO plan typically have to pay a copayment for each doctor visit. The amount of the copayment will vary depending on the plan.

Co-insurance

HMOs also typically require members to pay co-insurance for most services. This is a percentage of the service cost that the member has to pay.

Deductibles

HMOs often have a deductible, the amount of money that the member has to pay before the insurance company starts paying for services. This deductible may be per year or episode of care (for a hospital stay).

Choose The Right Plan For You

Nesso Senior Benefits can help you choose the right plan for you. We understand that all the different options can make the decision overwhelming. That’s why our team of professionals gathers all the necessary information to provide you with all the facts to make an informed decision. 

At Nesso Group, we work hard to provide a customized plan for your specific needs. Medicare is a complex program with numerous rules, regulations, and restrictions. We assist you in navigating the ever-changing complexities of Medicare and keep you informed on new developments. Contact us now to get started. 

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