•HMO enrollees must generally only use doctors and hospitals within the plan’s network (known as participating providers) for services to be covered. However, there are certain exceptions:
Emergency services received outside of the plan network are covered.
When the enrollee is temporarily absent from the plan’s service area, dialysis services are covered outside of the network.
Urgently needed services received outside of the plan network are covered when the enrollee is temporarily outside of the service area or in rare circumstances when the network is not available.
If a needed specialist or a covered procedure is not available through the network, the plan will authorize out-of-network services.
•The mandatory MOOP for HMOs in 2023 is $8,950, although it is likely that many will have lower limits.
•HMO enrollees may need to select a primary care doctor and may need a referral for specialty care
•If an HMO enrollee needs a type of specialist who is not available in the plan’s network, the plan will arrange for care outside of the network.
•Some HMOs offer a Point of Service (POS) option that allows enrollees to go to non-plan doctors and hospitals without receiving prior approval for certain services. Unlike a PPO, an HMO-POS plan may limit the services available out of network or may put a dollar cap on the amount of out-of-network coverage. Cost-sharing is generally higher than for services obtained from network providers.
HMO Point-of-Service (HMOPOS) plans are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance. It’s important that you follow the plan’s rules, like getting prior approval for a certain service when the plan requires it.
Are prescription drugs covered in Health Maintenance Organization (HMO) Plans?
In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want Medicare drug coverage (Part D) , you must join an HMO Plan that offers prescription drug coverage. If you join an HMO plan without drug coverage, you can’t join a separate Medicare drug plan.
Do I need to choose a primary care doctor in Health Maintenance Organization (HMO) Plans?
In most cases, yes, you need to choose a primary care doctor in HMO Plans.
Do I have to get a referral to see a specialist in Health Maintenance Organization (HMO) Plans?
In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don’t require a referral.
What else do I need to know about this type of plan?
If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.
If you get health care outside the plan’s network , you may have to pay the full cost.
It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.
The upside to HMOs is that they tend to cost a lot less. If you don’t need a lot of specialized care and don’t mind the network restrictions, a Medicare Advantage HMO plan could work for you.
