Health Maintenance Organizations (HMOs) must provide you with the same benefits as Original Medicare but may do so with different rules, restrictions, and costs. HMOs can also offer additional benefits. Below is a list of general cost and coverage rules for Medicare Medicare is the federal government health insurance program that provides health care coverage if you are 65 or older, are under 65 and receive Social Security Disability Insurance (SSDI) for 24 months, begin receiving SSDI due to ALS/Lou Gehrig’s Disease, or have End-Stage Renal Disease (ESRD) no matter your age. You can receive health coverage directly through the federal government (see Original Medicare) or through a private company (see Medicare Advantage). HMOs. Remember to speak to a plan representative to learn the details about any plan you are considering.
Costs
- Plans may charge a monthly in addition to the Part B Part B, also known as medical insurance, is the part of Medicare that covers most medically necessary doctors’ services, preventive care, hospital outpatient care, durable medical equipment (DME), laboratory tests, x-rays, mental health services, and some home health care and ambulance services. premium, or choose to pay part of your Part B premium. Plans may charge a higher premium if you also have Part D coverage.
- Plans may set their own deductibles, copayments, and other cost-sharing Cost-sharing is the portion of medical care costs that you pay yourself, such as a copayment, coinsurance, or deductible, if you have health insurance coverage. See also: Out-of-Pocket Costs. for services.
- All HMOs must set an annual limit on your out-of-pocket costs Out-of-pocket costs are health care costs that you must pay because Medicare or other health insurance does not cover them. . This limit may protect you from excessive costs if you need a lot of care or expensive treatments. The maximum out-of-pocket limit See Maximum Out-of-Pocket (MOOP). for HMOs in 2025 is $9,350, but plans may set lower limits.
- HMOs cannot charge more than Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. charges for certain kinds of care, including chemotherapy, dialysis Dialysis is the treatment used to artificially cleanse your blood of toxins when your kidneys no longer work. , and skilled nursing facility (SNF) Skilled nursing facilities (SNFs) are Medicare-approved facilities that provide short-term post-hospital extended care services. care. However, HMOs can charge higher copays for other services, including home health, durable medical equipment (DME) Durable medical equipment (DME), also known as DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) is equipment that primarily serves a medical purpose, is able to withstand repeated use, and is appropriate for use in the home; for example, wheelchairs, oxygen equipment, and hospital beds. Medicare only covers DME if your provider says it is medically necessary for use in the home. , and inpatient An inpatient is a patient who has been formally admitted into the hospital by a doctor. Most inpatient care is covered under Medicare Part A (hospital insurance). hospital care.
Providers
- You need to select a primary care provider (PCP) The primary care provider (PCP) is the doctor or other health care worker who manages your health care and gives you a referral to consult a specialist if you need it. In Medicare Advantage, many Health Maintenance Organizations (HMOs) require you to select a PCP and get their permission or referral before seeing a specialist. Preferred Provider Organizations (PPOs) and Private Fee-for-Service (PFFS) plans do not have this requirement. who coordinates your care. You usually must get your PCP’s permission or referral Referrals are authorizations that Medicare Advantage Plans usually require for services not provided by your primary care provider (PCP). For example, Health Maintenance Organizations (HMOs) generally require you to get a referral from your PCP in order to see a specialist or get an eye exam. before seeing a specialist A specialist is a doctor who specializes in treating only a certain part of the body or a certain condition. For instance, a cardiologist only treats people with heart problems. .
- Generally, you are only covered for care you get from in-network providers and facilities. Except in emergencies or urgent care Urgent care is immediate medical attention for a sudden illness or injury that is not life threatening. situations, you will pay the full cost of the care you receive from Out-of-Network Out-of-network means not part of a private health plan’s network of health care providers. If you use doctors, hospitals, or pharmacies that are not in your Medicare Advantage Plan or Part D plan’s network, you will likely have to pay the full cost out of pocket for the services you received. providers. Keep in mind that doctors may leave the HMO’s network at any time (even during the plan year). Your plan should notify you if any of your providers leave the network.
- If you need emergency or urgent care and are outside your plan’s service area The service area is the geographic area where a Medicare Advantage Plan or Part D plan provides medical services to its members. In many plans, the service area is where your network of providers is located. , your plan must cover the care even if it is provided by an out-of-network doctor.
- Some HMOs offer a Point-of-Service (POS) option The Point-of-Service (POS) option is offered in some Health Maintenance Organization (HMO) plans. Most HMOs only cover care from in-network providers, except in case of emergency. The POS option allows you to receive coverage for certain services out of network, but usually at a higher cost. , which allows you to see out-of-network providers for certain services without referral or . You may pay more than you would when seeing an in-network In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers. provider, but plans must have a limit on your out-of-pocket costs when you use the POS option.
Benefits
- Your HMO may offer additional benefits, such as vision, hearing, and/or dental care. Check with the plan directly to learn about coverage rules and restrictions for any added benefits.