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, 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 premium, 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.
Typically you cannot have an HMO if you have End-Stage Renal Disease (ESRD), unless:
- You join a Special Needs Plan (SNP) HMO that specifically takes beneficiaries with ESRD
- Or, you were enrolled in an HMO prior to developing ESRD and you choose to stay in that HMO
Note: If you remain enrolled in an HMO after developing ESRD and the plan leaves your area, you have a Special Enrollment Period (SEP) to enroll in another HMO in your area.
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 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, which allows you to go out of network 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 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.
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