How Medicare HMOs compare with Original Medicare

Section V.a. Medicare HMOs
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HMOs (Health Maintenance Organizations) and Original Medicare differ in five key ways:

  1. Providers you can use. HMOs will usually only cover your care from doctors and hospitals in their network, except in the case of emergency or urgent care. Original Medicare will cover your care from most doctors and hospitals in the country. HMOs usually require that you receive a referral from your primary care physician before you can get care from a specialist, while in Original Medicare you do not need to get a referral.
  2. Benefits. HMOs must offer all the benefits available under Original Medicare (Part A and Part B).  Many Medicare HMOs also offer Medicare prescription drug coverage (Part D). If you are in a Medicare HMO, and you want Medicare drug coverage, you must get your drug coverage from that same plan. Some HMOs may offer additional benefits that Original Medicare does not cover, such as dental care or eye care.
  3. Premium. In Original Medicare, you pay only the Part B premium. HMOs may charge a monthly premium in addition to the Medicare Part B premium. The premium may be higher if the HMO offers prescription drug coverage (Part D) benefits. When you are in an HMO you must continue to pay the Part B premium.
  4. Out-of-pocket costs. With Original Medicare you generally pay 20 percent coinsurance for doctors' and other medical services. Supplemental insurance such as a Medigap or a retiree plan could help pay for that coinsurance. In an HMO, you usually pay a fixed amount for services (copayment). HMO copays cannot be higher than Original Medicare for some services, like chemotherapy, dialysis and durable medical equipment, but could be higher for other services, such as home health and hospital.  Also, unlike Original Medicare, private health plans must have a cap on out-of-pocket costs to protect you against very high costs if you receive expensive care.
  5. Affordability. If you are generally healthy and only see doctors and other providers in the HMO's network, your out-of-pocket costs may be lower than in Original Medicare. Also, since HMOs include a limit on out-of-pocket costs, you are protected from very high costs if you use need a lot of medical care or expensive treatments.  If you use doctors and hospitals that are not in the HMO’s network, or you see many providers your, costs might be higher. You cannot buy supplemental insurance to fill the gaps in HMO coverage.

Note: Many people who have Original Medicare also purchase a Medigap plan to help pay some of their costs (such as deductibles and copays). Medigap plans are supplemental insurance policies that work specifically with Original Medicare. You cannot have a Medigap and a Medicare HMO together.


Related Questions
Can my state give me more rights and protections than federal law regarding Medigap plan enrollment?

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LINKS
Joint Commission on the Accreditation of Healthcare Organizations

Medicare.gov Medigap (Medicare Supplement) Policies & Guide

The National Committee for Quality Assurance (NCQA)

State Health Insurance Assistance Program (SHIP) Directory

 
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