What Is a Medicare Advantage HMO Plan?

A Medicare HMO plan can be an excellent choice if you are looking for a low premium plan. In some cases, the premium may be $0. Like all Medicare Advantage plans, you need to be enrolled in Medicare Part A and Medicare Part B to access an HMO plan.

A Medicare Advantage HMO is one of the most limiting insurance plans available. You can only access out-of-network benefits in an emergency. Otherwise, you need to use an in-network provider. Medicare HMO plans also differ depending on where you live. Our locally based North Carolina Medicare agents can answer ‌questions about HMO plans and whether they’re right for you. 

Enrolling in a Medicare HMO Plan

In addition to being enrolled in Medicare Part A and Part B, you must live in your plan’s area. You also need to consent to only receive care via the plan’s network of providers, except for emergencies. 

Your insurance provider will establish contracts with specific health care providers in your area. You’ll typically be required to indicate a primary care physician (PCP) responsible for your health care. If any health conditions are outside their area of expertise, they will refer you to a specialist who is also in your plan’s network. Sometimes you won’t need a referral for these specialist services, such as preventative care or mammograms.

Medicare HMO plans can be restrictive. So if you’d rather have the flexibility of choosing your health providers, it can be better to consider selecting a Medicare PPO plan. 

Key features of Medicare Advantage HMO plans

Here are some of the most common things you can expect when enrolling in a Medicare HMO plan: 

• You only need to answer one question when applying for a Medicare HMO plan. Enrollment is open to anyone during the proper enrollment periods. The only exclusion is if you suffer from end-stage renal failure.

• With an HMO plan, your premiums may be lower than taking out a Medigap plan, depending on where you live. 

• Every plan includes a summary of benefits, which outlines how much each provider can charge you for specific services. Your copays for these services, such as doctor’s visits, can vary depending on your plan and provider. You will need to pay your copays as you go. 

• Most HMO plans also include Medicare Part D prescription drug coverage. If you need specific prescription drugs, check the drug formulary to see what’s included in your plan. 

• Premiums can vary each year, so it’s essential to review your Annual Notice of Change each year to understand what the changes mean for your premium. 

• In addition to annual premium changes, your provider network, benefits formulary, pharmacy network, and copayments can also change each year. Review your plan annually to decide if it’s still right for you. 

Need help finding the right Medicare HMO plan?

If you’re still wondering, ‘What is an HMO plan?’ or if you’re considering enrolling in an HMO plan, it can be worth seeking expert advice from a knowledgeable Medicare agent. At Health Plans of NC, our experienced team specializes in North Carolina Medicare and can do the hard work for you. We’ll do the research and provide you with the best options for your health care needs. Contact us today to find out more or compare plans online.