If you are enrolled in Medicare Parts A and B for your health care, you can move beyond the basic coverage provided by Original Medicare and get additional benefits with a Medicare Advantage (MA) Plan. There are several different types of Medicare Advantage Plans. All MA plans are provided through Medicare-approved private insurance companies, and each type of plan has its own structure.
One of the most popular and least costly of these MA plans is the health maintenance organization (HMO). When you join an HMO, you choose a primary care physician (PCP) from the HMO’s provider network. Your PCP will manage your care through the HMO’s network of facilities and doctors.
Who Should Get a Medicare HMO Plan?
A Medicare HMO plan may be a good health care choice for you if you:
- Don’t travel or typically need care outside of your service area
- Don’t mind choosing from in-network providers to receive all services
- Want the least expensive Medicare Advantage option
What Is a Medicare HMO Plan?
A Medicare HHMO plan is a type of Medicare Advantage Plan, an alternative to Original Medicare. An HMO provides you with access to your Medicare-covered services plus additional benefits through a specific network of physicians and facilities.
| Plan structure | Medicare Advantage Plan with an area provider network that you must use to access your benefits. |
| Benefits available | All Original Medicare benefits. Usually offers other benefits, such as prescription drug coverage, vision, dental, or hearing. |
| Cost sharing | Plans may have a premium and deductible, but most people have access to at least one zero-premium plan in their area. You pay copays for doctor and specialist visits, and copays or coinsurance for drugs. Medicare-covered services count toward your out-of-pocket max. |
How HMO plans work
HMOs, or health maintenance organizations, are often called managed care plans because your primary care provider is responsible for managing your care. First, you must choose a primary care provider in the network. Your PCP provides the majority of your treatment. For services your PCP doesn’t provide, you get referrals for care from in-network specialists. Every Medicare HMO plan is different, and the network of health care providers is the prevailing feature. Some HMO plans may not require referrals for all specialists, emergency services, or regular preventive care services, such as mammograms.
Unlike PPO plans, HMO plans may not pay for services you receive from out-of-network health care providers, except for urgent or emergency care you need outside of your service area. All Medicare Advantage HMO plans must set an out-of-pocket maximum amount. If you reach that amount, all Medicare-covered services that you receive in the network are free. Premiums, deductibles, copays, and coinsurance for drugs, and copays for additional benefits do not count toward your out-of-pocket max.
Benefits available with an HMO plan
You have all the benefits from Medicare Part A (hospital insurance) and Part B (medical insurance), including:
- Inpatient hospital and skilled nursing facility care
- Home health care
- Medically necessary outpatient care
- Primary care
- Preventive care
HMO plans may offer additional benefits that Medicare doesn’t cover like routine hearing, dental, and vision exams. These extra benefits are provided within a network and may charge an additional premium to get more comprehensive coverage. For instance, your HMO plan may cover routine dental exams, but plans may charge more for services like root canals or dentures. Most plans will offer prescription drug coverage. And you can see specialists. If you choose a plan that doesn’t include the drug coverage part, you cannot purchase a stand-alone Part D plan to get Medicare prescription drug coverage.
| Advantages of a Medicare HMO Plan | Disadvantages of a Medicare HMO Plan |
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Compare your Medicare options
See how a Medicare HMO compares to Original Medicare and other Medicare Advantage Plan types, including a Point-of-Service POS option, Preferred Provider Organization (PPO) and Private Fee For Service (PFFS) plan among others.
| Plan type | Costs* | Part A coverage | Part B coverage | Part D coverage | Out-of-state care** |
| Original Medicare | Part B premium | Yes | Yes | No | Yes |
| Medicare Advantage HMO | Part B premium plus plan premium | Yes | Yes | Usually | Emergency only |
| Medicare Advantage PPO (Preferred Provider Organization) | Part B premium plus plan premium | Yes | Yes | Usually | Emergency, plus other care if in your plan’s network, or you pay more for out of network |
| Medicare Advantage PFFS (Private Fee-for-Service) | Part B premium plus plan premium | Yes | Yes | Sometimes | Emergency, plus other care if contracted with your plan and agrees to treat you. |
| Medicare Advantage MSA (Medical Savings Account) | Part B premium plus high deductible | Yes | Yes | No | Emergency plus other care but you pay a higher cost for out of network if your plan has a network |
| Medicare Advantage SNP (Special Needs Plan) | Part B premium | Yes | Yes | Yes | Emergency and out-of-area dialysis plus other care if in your plan’s network |
*All plans include deductibles, copays, and/or coinsurance for services received. Medicare Advantage Plans have an out-of-pocket max that applies to Medicare-covered benefits. There is no cap on what you spend for Medicare Part A and Part B services, but if you purchase a Medicare Supplement Insurance (Medigap) plan ― which has a monthly premium ― it will cover most of Original Medicare’s cost-sharing requirements.
**Check with your plan for out-of-state coverage and service area.
Who Is Eligible for a Medicare HMO Plan?
A Medicare plan from a health maintenance organization is one of several types of Medicare Advantage Plans available to Medicare beneficiaries. In order to sign up for an HMO advantage plan, you must first have signed up for Medicare Part A and Part B coverage.
To be eligible for Medicare you must have turned 65 years old and be either a United States citizen or a legal resident for at least five years. If you’re under age 65, you may also be eligible if you have been receiving disability benefits from either Social Security or the Railroad Retirement Board (RRB) for a minimum of 24 months. If you’re diagnosed with amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease) or end-stage renal disease (ESRD), you are eligible for Medicare as soon as disability benefits begin.
How Much Does a Medicare HMO Plan Cost?
You can expect to pay the plan’s monthly premium in addition to your monthly Medicare Part B premium. Most Americans have access to a $0 monthly -premium maintenance organization HMO plan with prescription drug coverage in their area. With this type of advantage plan, you’re responsible for copayments and coinsurance for each service or drug received, after you have met your deductible. Most HMO plans require copays for certain services and treatments, and either copays or coinsurance for medications. Most HMO plans may charge for services you receive out of network, so there are some out-of-pocket costs. Drug coverage may not be included. If an over-the-counter OTC benefit is important to you, be sure to evaluate the plan to see if this is an option.
See how costs compare for these 2023 HMO plans for a 67-year-old female in Chicago:
| Plan name | Monthly premium | Deductible | Copay | Coinsurance | Out-of-pocket max |
| Humana Gold Plus | $0 | $0 medical, $0 prescription drug deductible | PCP: $0
Specialist: $15 |
100% out of network | $ 2,500 |
| AARP Unitedhealthcare | $0 | $0 medical, $0 prescription drug deductible | PCP: $0
Specialist: $30 |
100% out of network | $ 2,500 |
| Cigna Courage Medicare | $0 | $0 medical, $0 prescription drug deductible | PCP: $0
Specialist: $40 |
100% out of network | $ 6,700 |
How Do I Enroll in a Medicare Advantage Plan?
To join Medicare Advantage, you first need to be enrolled in Medicare Part A and Part B. After you join Medicare and enrolled in those coverage parts, you can enroll in an HMO plan during your Initial Enrollment Period (IEP) or during other times throughout the year:
- IEP: This seven-month period starts three months before the month of your 65th birthday, the month of your birthday and ends three months after your birthday month.
- Initial Coverage Enrollment Period (ICEP): This is the opportunity for those who want to enroll in a Medicare Advantage Plan and often occurs at the same time as the IEP for Original Medicare.
- Annual Enrollment Period (AEP): This period runs from October 15 through December 7.
- Medicare Advantage Open Enrollment Period (OEP): Medicare beneficiaries who already enrolled in a Medicare Advantage Plan can switch plans between January 1 and March 31.
Use the Medicare Plan finder to research available HMO plans in your area. The tool will ask you to provide information such as your ZIP code to find plans near you. Advantage plans may differ in availability and cost based on where you live. When you’ve chosen a plan, go to the insurer’s website to check for online enrollment options or contact the insurance company by phone or email to request a paper enrollment form. You can also enroll by calling Medicare at (800) 633-4227.
To enroll, you need your Medicare number and the date your Parts A and B coverage began. Your Medicare card has this information.
Should You Get a Medicare HMO Plan?
Each type of Medicare Advantage plan offers its own advantages and disadvantages. A Medicare health maintenance HMO plan makes the most sense for plan members who are looking for the lowest possible monthly premiums, don’t mind getting all of your care from your plan’s network of providers, don’t travel much, or need a great deal of specialty care.
Learn More From Our Sources
- CMS | Fact Sheet 2021 Medicare Part A & B Premiums and Deductibles | Last accessed November 2024
- Medicare | Common Types of Medicare Advantage Plans | Last accessed November 2024
- Medicare | What Medicare Covers | Last accessed November 2024
- Medicare | Your Medicare Costs at a Glance | Last accessed November 2024
- Medicare | Find a 2022 Medicare Plan | Last accessed November 2024
- Social Security Administration | Benefits Planner | Last accessed November 2024