Medicare Health Maintenance Organizations (HMOs) are private plans that the federal government pays to administer Medicare benefits. Like all Medicare Advantage Plans, HMOs must provide you with the same benefits, rights, and protections as 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. , but they may do so with different rules, restrictions, and costs. Some HMOs offer additional benefits, such as vision and hearing care.
Eligibility and costs basics
You must have both Parts A and B to join a Medicare HMO. Generally you will continue paying your Medicare 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. , though some HMOs will pay part of this premium. Some HMOs may charge an additional premium, on top of your Part B premium. If you want Part D coverage, you will receive it through your HMO. Plans may charge a higher premium if you also have drug coverage.
Note: If you join a Medicare Advantage Plan and you want Part D coverage, you must receive coverage from your plan. You cannot enroll in stand-alone Part D coverage unless you join a Medical Savings Account (MSA) or Private Fee-for-Service (PFFS) plan that does not offer prescription drug coverage.
Benefits access basics
Once you have joined an HMO, you should receive a benefit card from your plan. You will use your HMO benefit card instead of your Medicare card Everyone who enrolls in Medicare receives a red, white, and blue Medicare card. It lists your name and the dates that your Original Medicare hospital insurance (Part A) and medical insurance (Part B) began. It also shows your Medicare number, which serves as an identification number in the Medicare system. If you get Medicare through the Railroad Retirement Board, your card will say “Railroad Retirement Board” at the bottom. If you are enrolled in a Medicare Advantage Plan, you will also have a card from that plan (see Medicare Advantage Plan Card). when you go to the doctor or hospital.
In most HMOs, you must see in-network providers to receive coverage, unless you need emergency medical treatment. 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 go out of network A network is a group of doctors, hospitals, and pharmacies that contract with a Medicare Advantage Plan to provide health care services. Generally, plan members will have the lowest costs when using providers and facilities in the plan’s network. Networks may be made up of both preferred and non-preferred providers. for certain services. In these cases, you will be covered but usually at a higher cost.
Medicare HMOs are not available everywhere. Call 1-800-MEDICARE (1-800-633-4227) or your State Health Insurance Assistance Program (SHIP) to find out if there is an HMO available in your area. To enroll in an HMO, call Medicare or the plan directly. Be sure to make an informed decision by contacting a plan representative to ask questions before enrolling.