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Medicare Health Maintenance Organization - (HMO Plans)

Many people have had good experiences with HMO plans through their employer group health program.   When transitioning from an employer-based health plan to a Medicare Advantage plan, the HMO plans typically offer much smaller networks. 

For instance, the Anthem HMO employer plan will not typically be the same networks offered through an Anthem Medicare Advantage HMO plan.  Many people will stay with the same insurance company, believing their network doctors and medical facilities will remain the same.  Many Medicare advantage plans may have 16 or more different networks within a specific city. 

Medicare advantage plans are mostly HMO Plans.  This means, your healthcare services must be obtained from a provider that is within your plan’s network.  A following three exceptions may apply:

  • Emergency care
  • Out-of-area urgent care – (Review your plan documents, as your Medicare advantage plan may exclude out of network urgent care facilities)
  • Out-of-area dialysis – (Review your plan documents, as your Medicare advantage plan may exclude out of network dialysis facilities)


Some Medicare insurance providers, offer a point-of-service (POS) option included as part of their HMO plans offering.  If the Medicare plan you select offers this type of Medicare plan, you may be able to go out-of-network for certain services. The cost for services rendered out of network are typically much higher.  It is always best, when possible, to remain within your network of providers.  Medicare advantage fall under Part C of Medicare.  Find and compare HMO Plans in your area with our online plan finder tool.

Before you are allowed to enroll into a Medicare advantage plan, you are required to enroll into Part A and Part B of Medicare. 

All Medicare Advantage HMO plans must cover at least:

  • Part A services: including hospital insurance, hospice care, and limited skilled nursing facility and home healthcare
  • Part B services: including preventive care and tests, necessary home medical equipment, outpatient procedures, and more

If you are not happy with the restrictions applied towards HMO plans, you can consider a PPO Medicare advantage plan.  You may want to consider a Medigap plan as well if you fall into the guaranteed issue period. 

If you are outside the guaranteed issue period of a Medigap plan or you have medical issues which does not allow you to obtain a Medicare supplement plan, a PPO Medicare advantage plan may be your best option.

Medicare Advantage HMO Plans

Medicare HMO Plans Common Features

  • Medicare advantage HMO plans application process. The application process is simple and streamlined. There is no medical question included that would prevent you from obtain coverage from an Advantage plan.
  • Medicare Advantage Plan Premiums. Depending on where you live your area may or may not include an additional monthly premium. Many HMO Medicare advantage plans have $0.00 monthly premiums, and some include Part B premium rebates. Review your plans annually, as HMO plans do change each year. 
  • Review your Annual Notice of Change letter each fall. This letter outlines the upcoming changes to your Medicare HMO plan for the next year. The letter will identify areas where they have increased coverages and reduced coverages.  This includes healthcare benefits, Part D prescription drug benefits, premium changes, copayment, max out of pocket cost, and co-insurance adjustments.
  • Local HMO plans medical provider network changes.  Medicare advantage HMO plans renegotiate network provider groups on an annual basis.  Doctors and hospitals from which you must seek care, can and will change. You need to ensure your doctors are remaining with the medical group you selected, prior to scheduling an appointment.  You may need to change your medical group.  HMO plans will have you choose a primary care physician.  It is important this physician is included within your plans network, or you will be obligated to cover the bill in full.
  • Medicare Part D drug plans.  MAPD plans include your Part D prescription drug coverage. You are only offered a single prescription drug plan within the Medicare advantage plan.  Review the Part D drug formulary with your Medicare insurance agent, to make sure your medications are included in the plan.  Also verify which Tier your medications are covered under.
  • Medicare Advantage HMO plans are considered “You pay as you go plans”.  As many advantage plans do not charge an additional monthly premium, they may require Medicare beneficiaries to pay in the form of co-pays, deductibles, and coinsurance. Each plan includes a summary of benefit which outlines the cost for each serve rendered. The cost will vary for the types of services like doctor’s visits, outpatient surgeries, lab-work, and inpatient hospital care.
  • Special Needs HMO Plans. HMO Medicare advantage plans, offer special needs plans.  These plans are tailored for individuals who have specific medical conditions.  If you have been diagnosed with type 2 diabetes you may qualify for lower insulin cost through one of these specialty plans. 

Medicare HMO plans offer several benefits that have attracted many Medicare beneficiaries to them.  They have grown in their popularity over the past 10 years and are expected to exceed in their popularity over Medicare supplement plans in the next few years.  It is important to understand all options and know the pros and cons.  Working with your Medicare insurance brokers to navigate through the different plan options, will give you the ability to make a more informed decision.

HMO Plans

Are Prescription Drugs Covered In Health Maintenance Organization HMO Plans?

In most cases, your Part D prescription drugs are covered within HMO Plans. These plans are known as Medicare Advantage Prescription Drug (MAPD) plans.  Your Medicare advantage insurance brokers can assist you in finding the correct plan type based on your medical needs. 

If you require Medicare drug coverage (Part D), you will need to join an HMO Plan that includes prescription drug coverage. 

Some military veterans who receive their care from a VA medical facility, have creditable Part D coverage through the VA.  In this instance, the veteran would not need a MAPD plan, but rather a Medicare advantage plan known as a MA plan. 

If you mistakenly sign up for a MA plan without Part D coverage, you are not allowed to join a separate Medicare drug plan.  You will also incur a lifetime penalty for each month you are without a creditable Part D plan. 

Do I need to choose a primary care doctor in Health Maintenance Organization HMO Plans?

HMO plans are considered managed care, which will require you to choose a primary care doctor.  Your primary care doctor is known as the plans gatekeeper.  This means they oversee your overall healthcare needs.

Do I Need A Referral To See A Specialist In Health Maintenance Organization HMO Plans?

When you are part of an HMO, you are required to obtain a referral to see a specialist. Some Medicare advantage plans will outline certain services which may not require a referral.

It is always important to review your plan documents annually to verify how your coverage works from year to year.

Should I Sign Up For A Medicare Advantage Plan?

Everyone’s healthcare needs are different.  What is considered a great plan for one individual, may not be the best Medicare plan for someone else. 

It is important to review the different Medicare plan options, to ensure the plan you select is best for you. 

Your Medicare insurance agent, will help you decide is a Medicare advantage plan or Medicare supplement plan would serve you best.

Follow the money related to Medicare Cost

How Do Medicare Advantage Companies Make Money?

Medicare advantage plan companies are paid directly from Medicare which is a governmental entity.  With the money each of these private companies receive, they are tasked to manage their cost and your healthcare needs.   

Depending on the company’s star ratings, the more or less the government will pay to them for each enrolled Medicare beneficiary. 

Once you are enrolled into a Medicare advantage plan, your providers will bill no longer bill Medicare.  They will now bill your HMO Medicare advantage plan company for payment. 

Which Insurance Companies Offer Medicare HMO plans?

Many of the most well-known insurance companies offer Medicare advantage plans.  This includes Aetna, Anthem, Blue Cross Blue Shield, Cigna, Healthnet, United Healthcare, and many more. 

Each of these Medicare insurance companies offer dozens of plans under their umbrella of insurance. 

Each of these plans offer different level of insurance coverage.  It is important to select the best plan for your specific healthcare needs. 

If you select the wrong plan, this can cost you tens of thousands of dollars in medical and prescription drug cost.

Doctor Office

Can I Keep My Doctors With A Medicare HMO Plan?

The answer is maybe. Depending on the number of doctors you currently have, we may be able to find a Medicare HMO plan that includes all your doctors.  Often, we are only able to cover a couple or a few of your doctors and you may need to change out your other doctors. 

Depending on the number of Medicare insurance companies, the plans they offer, and the number of medical groups included within those plans can make including your doctors easy or difficult. 

Finding a Medicare HMO plan to cover your primary care doctor is usually very easy.  However, as we start adding your specialist doctors to the list, this is where the challenge begins.

As a Medicare beneficiary covered by a Medicare HMO plan, you will need to decide if all your doctors are required.  If the answer is yes, then you may need to either select a more expensive PPO Medicare plan or select a Medicare supplement plan. 

If you select a Medicare supplement plan, the restrictions of medical networks disappear.  You now have the freedom to see any doctor if they accept Medicare patients.  Nearly all doctors across the US accept Medicare.

For those individuals who travel the country on a regular basis, a Medicare supplement plan is usually their best option.  They do not need to worry about not being able to see a doctor in another state.  They also don’t need to hassle with referrals or medical pre-authorizations.

Without the need of a medical pre-authorization, you can receive your required medical care immediately.  You can also go to any medical facility that you are seeking services from. God forbid you get cancer, with a Medigap plan you have the freedom to be seen in any of the top cancer facilities that specialize in your particular cancer.

How Long Do Prior Authorizations Take To Be Approved?

Depending on the HMO Medicare advantage plan company, prior authorizations can take anywhere from a few days to several months to receive approval for a medical procedure. 

The Medicare advantage plan also has the option to deny approval, if the network believes the procedure is not medically necessary. 

Your doctor does not have the authority under an HMO Medicare advantage plan to decide what is considered medically necessary. 

Medicare Supplement Cancelled

My Medicare Advantage Plan Denied My Doctors Pre-authorization Request

If your HMO Medicare advantage plan denies your doctors request for a medical procedure, you have the option to file an appeal of the denied request. 

Depending if the denial is from a Medicare advantage plan appeal or Original Medicare appeal the process can be slightly different.

If your doctors request for healthcare services are ever denied by Medicare, you or your doctor should appeal the decision 100% of the time.

Medicare Part D Prescription Drug Coverage Denial

If your Part D prescription drug is denied from the Medicare insurance company, you have the option to appeal this denial. 

This applies to Medicare advantage plans and standalone Part D plans. 

Which Medicare Advantage Plan is Best?

This is a common question asked by our clients.  Often, they start the conversation off with, my friend or family member says that SCAN Health Plan is the best plan for our area.  We wish it was as easy as this, as that would make our jobs very simple. 

Selecting a Medicare advantage plan is a much more complicated process.  We need to review your complete healthcare needs.  This includes evaluating the following information:

  1. List of your doctors.
  2. Medical facilities you require to be included within your medical network.
  3. Which company and plan includes your medical network?
  4. Are your prescription drugs covered under these plans?
  5. Which Medicare advantage plan will cost you the least based on your health?
  6. Are you okay being enrolled into a medical network?
  7. Do you want the freedom of a Medicare supplement plan?
  8. Would a standalone Part D plan work better for you?


Depending on how you answer some or all these questions, may impact the recommendations we will offer as your best solution. 

The great news is by working with an independent insurance agent, we have access to every Medicare insurance company and their plans.  You also gain access into a Medicare expert, to guide you through the entire process. 

How Are Medicare Advantage Agents Paid?

Your independent Medicare advantage agent is paid directly from the insurance company we place you with.  There is no cost difference, if you selected a plan directly from the insurance company or used an insurance agent.

Most often Medicare beneficiaries save money by using Medicare insurance brokers, as they can analyze all companies and plans.  They are not restricted to only showing you a single plan within a single company. 

A Medicare insurance agent is paid the same amount no matter which insurance company they place you with.  This is because Medicare has standardized these payments for all Medicare advantage plans.

Medicare insurance agents come at no additional cost to the consumer. 

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What Else Do I Need To Know About This Type Of Plan?

  • Medicare advantage plans can change annually.  It is important to confirm your doctors and medical facilities remain on your plan each year. 

  • If you obtain medical care outside the plan’s network, you may have to pay the full cost.

  • Non-emergency care obtained at an emergency room, may be excluded from coverage. 

  • HMO Medicare advantage plans have different rules than a Medigap plan.  It’s important that you follow the plan’s guidelines, to ensure your medical bills will be covered. 

  • HMO plans typically require prior network authorization approval for a certain needed medical service. 

  • Referrals to see specialist are required for most services under an HMO plan.


Learn More About Medicare HMO Plans

Integrity Now Insurance Brokers is one of the top Medicare insurance agencies across the United States.  We have helped thousands of Medicare beneficiaries find the right plan for their needs. 

By working with our licensed Medicare insurance agents, you instantly gain the expertise you have been looking for. 

We will help you navigate all available Medicare plans in your local area. 

If a Medicare HMO plan is your best option, this will be the direction we will help you with. 

You may not like the restriction HMO plans place on your healthcare needs.  If this is the case, we will recommend a Medicare supplement plan. 

Many people want the Medicare supplement Plan G, as it offers a very comprehensive plan.  Medigap plans bring stability to your monthly budget as they are predictable. 

Medigap plans also provide the freedom to see any doctor and medical facility.

No matter what type of Medicare plan you prefer (HMO Plans or Medigap Plans), we are here to help you select your best Medicare plan.

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