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 HMOs. Remember to speak to a plan representative to learn the details about any plan you are considering.
- Plans may charge a monthly premium in addition to the Part B 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 for services.
- All HMOs must set an annual limit on your out-of-pocket costs. This limit may protect you from excessive costs if you need a lot of care or expensive treatments. The maximum out-of-pocket limit for HMOs in 2019 is $6,700, but plans may set lower limits.
- HMOs cannot charge more than Original Medicare charges for certain kinds of care, including chemotherapy, dialysis, and skilled nursing facility (SNF) care. However, HMOs can charge higher copays for other services, including home health, durable medical equipment (DME), and inpatient hospital care.
- You need to select a primary care provider (PCP) who coordinates your care. You usually must get your PCP’s permission or referral before seeing a specialist.
- Generally, you are only covered for care you get from in-network providers and facilities. Except in emergencies or urgent care situations, you will pay the full cost of the care you receive from out-of-network 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, 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, which allows you to see out-of-network providers for certain services without referral or prior authorization. You may pay more than you would when seeing an in-network provider, but plans must have a limit on your out-of-pocket costs when you use the POS option.
- 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.