Medicare HMO – What You Don’t Know Could Hurt You

What is a Medicare HMO?

A Medicare HMO is a Medicare Advantage Plan with a Health maintenance Organization as the provider network. Most Advantage Plans are network-based but not all work the same way.

When enrolled in a Medicare HMO you must abide by the rules set by the plan. There are two things that distinguish an HMO from other types of Advantage Plan networks.

  1. You must choose a primary care provider and get referrals from that provider to use the services of other specialists and facilities.
  2. You must receive all of your services from the Health maintenance Organization network.

On the surface those two points are acceptable, but they could pose problems under certain circumstances. You could be frustrated later on if you don’t think these things through before you enroll in a plan.

Don’t let this happen to you

While getting referrals for every issue limits you freedom to manage your healthcare, the bigger problem arises when you need a provider or a specific type of procedure that is not offered within the HMO network.

Let’s assume for a minute that you are diagnosed with a rare form of cancer. The good news is, it treated in-network with some success, but the leading treatment with the highest record for success is only available at a specialty hospital which is not in your network.

You know that this leading treatment exists and you know that the positive results are real. But you cannot go out-of-network for treatment. Your Medicare HMO will not pay for it. And as long as you are enrolled in the HMO, Medicare won’t either.

If you had original Medicare or original Medicare and a supplement, you would have no problem getting the leading treatment. If enrolled in a Medicare PPO, you could pay a little more and go out-of-network and get the leading treatment. But not with the HMO.

How should you proceed?

Medicare HMOS are popular. You will often find more HMOS in service areas with major metropolitan areas than other types of Advantage Plan networks.

It’s enticing to enroll in this type of plan because the cost-sharing amounts (deductibles, copays and coinsurance) are often lower than plans with other types of networks. And often these plan have richer ancillary benefits, like dental, vision, hearing and gym memberships than some other non-HMO plans.

Before you enroll in a plan you need to investigate the network thoroughly. No one has a crystal ball, but doing some research before you enroll can give you a better idea about what services are available. Consider your health and your family’s health history to play the what if game. Thinking through possible scenarios could save you some frustration in the future.