Medicare HMO Costs & Benefits

A Medicare HMO is a viable option for those who wish to limit their out of pocket medical expenses. It should be known that not all parts of the United States have Medicare HMO benefits as an option. Generally, the more urban areas and areas that have a higher concentration of Medicare eligible residents will have one or multiple Medicare HMOs as an option. The Medicare HMO is a type of Medicare Advantage Plan.

Medicare HMO benefits are generally free of charge with no monthly premiums. One would still have to pay the monthly expense of the Medicare part B premium which is $96.40 in 2012. Medicare HMO Advantage Plans

Medicare HMO benefits are simple and easy to understand. The Medicare HMO will claim that they provide preventive healthcare that focuses on maintaining your health but the fact is that when a Medicare HMO member gets sick he or she will simply go to the doctor and have minimal out of pocket costs.

How Does an Medicare HMO Advantage Plan Work for You?

Medicare HMO Advantage plans are quite different from other types of health insurance plans in the manner they deal with the cost of health care and the services they provide.

Medicare HMO Advantage Plans make an effort to keep the cost of healthcare as low as possible. This can happen in a number of ways. For instance, HMOs make out how much they would pay for health care and services. Thereafter, they contract with the physicians and hospitals which accept those payments readily.

In a lot of cases, HMOs fork out physicians a defined sum of money each month for each patient they see. Policy holders need to get their care from the physicians, hospitals and other insurance providers who work with the HMO. This is addressed as a network.

Usually, the HMO Medicare Advantage Plans solely pay for operations or procedures that they can show are effectual. They may need their members to try lower priced tests or procedures before they will cover the ones that cost more.

HMOs normally ask its members to pay money partially for their treatment. Policy holders are asked to possibly fork out specified amount of money, titled as co-payment, for each service that they obtain. The HMO Medicare plans may additionally have an annual deductible. Deductible is the amount of money that the policy holders have to give on an annual basis before HMO pays for your treatment. Co-payments and deductibles assist in holding the cost of health care down.

Under the HMO Medicare Plan, members need to get approval prior to getting paid by HMO for the services and procedures. This generally implies that the primary care doctor has to give referral before the HMO pays. If the policy holders receive services without any referral or approval, then they might have to pay full cost for all the services.

In case the HMO does not approve any service or procedure, the member or the physician can appeal the decision with the HMO. In worst situations, if the HMO still does not pay for the treatment, the member has an opportunity to make an appeal to HMO Help Center.

An HMO Medicare Advantage Plan may be Right for you if:

  • You need an insurance plan without deductible and don’t care having an out-of-pocket limit.
  • You need an insurance plan with low premiums.
  • You require coverage for medical checkups and immunizations.

Using Your Medicare HMO Advantage Plan:

In case you require seeing a physician for a routing medical check-up, you will generally need to pay a co-payment for that visit. A co-payment for the visit can be as low as $10.

One does not need to make any claim; simply showing Medicare HMO card and making your co-payment will do the task. Rest, you don’t need to worry about as it will all be taken care of for you. A big advantage of a Medicare HMO Advantage plan is that it saves a lot of extra paperwork.

Nevertheless, one must keep in mind that under HMO, you are only covered for in-the-network insurance providers. Your Medicare HMO Plan would not pay for any treatment done by doctors out of the network.

Luckily, most of the HMO network comprise of thousands of physicians and hospitals. So, determining the best one for you should not be a problem.

Finding a Primary Care Physician (PCP):

With a Medicare HMO plan, you will have to choose your Primary Care Physician (PCP). He would be a doctor whom you would visit first in case you need any kind of medical care.

If you are not satisfied with your PCP or wish to consult any other physician, then your Primary Care Physician will need to give you a referral. In case you don’t take referral, then your Medicare HMO Advantage Plan would not cover you for that care.

What kinds of physicians can likely be considered as a PCP?

  • Family Doctors
  • Pediatrician
  • Obstetrician / Gynaecologist
  • Doctors of Internal Medicine

Difference between PPO Plans and HMO Plans:

Preferred Provider Organization (PPO) Plan
Health Maintenance Organization (HMO) Plan
Are prescription medications covered? In most cases, yes. Ask the plan. If you want drug coverage, you must join a PPO Plan that provides prescription drug coverage. In most of the cases, yes. Ask the Medicare plan. In case you need drug coverage, you got to enroll yourself in a Medicare HMO Advantage Plan that provides prescription drug coverage.
Do you require choosing your Primary Care Doctor (PCP) No In most of the cases, yes.
Can you get medical care from any physician or hospital? Yes. Under PPO, one gets to choose in-network doctors, but one can also obtain services from out-of-network providers at a higher cost. No. You normally ought to obtain services from the doctors within the plan’s network. If your insurance plan provides Point-of-Service, you can go for out-of-network for particular services for a higher cost.
Do you require getting referral to see a specialist? No Yes. But, yearly screening mammograms and in-network pelvic examinations do not need any kind of referral.
What else you need to know about this Medicare Advantage Plan?
  • There are primarily two kinds of PPOs – Regional PPOs and Local PPOs.
  • Regional PPOs must limit your out-of-pocket expenses for Medicare-covered services.
  • In case your physician leaves the plan, your plan will inform you. You then get to choose any other doctor of your choice.
  • If you undergo any treatment outside the network, there are chances that you may have to pay full cost.
  • It is very important to follow the rules of the plan.


Benefits of Medicare HMO Advantage Plans:

• Low or no monthly health plan premiums with minimal co-paysPPO and HMO Advantage-Plans
• A selection of doctors and specialists at minimal co-pays
• A network of hospitals
• Prescription drug coverage benefits
• Additional benefits like dental, vision and hearing care
• Preventive care for prostate screening, mammograms & bone density screening
• Worldwide emergency coverage

Different markets in the United States have varying reimbursement rates from the federal government. The reimbursement rate is the amount of money that the government pays the Medicare HMO company on a monthly basis for each member on the company's membership rolls. A Medicare HMO member is generally confined to receiving medical care to the network of doctors and hospitals on the Medicare HMO network. In addition, the member will be assigned a primary care physician (PCP) who will manage the patient's benefits and refer the member to a specialist if needed.

In very competitive and well reimbursed Medicare markets, such as South Florida Medicare, there are numerous Medicare HMO's competing to entice the Medicare recipient to join their plan and numerous additional benefits are offered. If a low cost alternative to Medicare supplement is desired, it is a good idea to analyze the various Medicare HMO Benefits in the local market to choose the company that is most beneficial to you.

Medicare Supplement Comparison Rates in 2012

Please feel comfortable contacting our knowledgable staff for information and expertise. 

Medicare Advantage Plan
Monthly Payments (Average)
Number Of MA Contracts
Advantage Plan Penetration
United States $734 United States 428 United States 17.5%
Alabama $692 Alabama 41 Alabama 15.2%
Alaska NA Alaska 39 Alaska 0.5%
Arizona $651 Arizona 50 Arizona 30.1%
Arkansas $640 Arkansas 39 Arkansas 8.23%
California $652 California 52 California 30.7%
Colorado $649 Colorado 37 Colorado 28.2%
Connecticut $681 Connecticut 40 Connecticut 9.1%
Delaware $658 Delaware 37 Delaware 2.23%
District of columbia $776 District of columbia 41 District of columbia 8.12%
Florida $840 Florida 74 Florida 23.1%
Georgia $680 Georgia 49 Georgia 8.1%
Hawaii $639 Hawaii 41 Hawaii 34.4%
Idaho $647 Idaho 40 Idaho 18.2%
Illinois $680 Illinois 56 Illinois 7.22%
Indiana $641 Indiana 45 Indiana 9.5%
Iowa $618 Iowa 42 Iowa 11.8%
Kansas $675 Kansas 44 Kansas 6.2%
Kentucky $653 Kentucky 45 Kentucky 8.4%
Louisiana $855 Louisiana 42 Louisiana 16.1%
Maine NA Maine 38 Maine 2.23%
Maryland $815 Maryland 41 Maryland 5.5%
Massachusetts $737 Massachusetts 42 Massachusetts 14.2%
Michigan $816 Michigan 44 Michigan 14.1%
Minnesota $645 Minnesota 40 Minnesota 26.2%
Mississippi NA Mississippi 38 Mississippi 6.51%
Missouri $663 Missouri 45 Missouri 15.2%
Montana $591 Montana 38 Montana 11.2%
Nebraska $650 Nebraska 37 Nebraska 8.21%
Nevada $757 Nevada 41 Nevada 29.1%
New Hampshire $653 New Hampshire 33 New Hampshire 2.1%
New Jersey $807 New Jersey 42 New Jersey 8.2%
New Mexico $651 New Mexico 41 New Mexico 20.1%
New York $811 New York 64 New York 21.2%
North Carolina $647 North Carolina 40 North Carolina 13.3%
North Dakota $591 North Dakota 37 North Dakota 5.51%
Ohio $674 Ohio 54 Ohio 17.1%
Oklahoma $666 Oklahoma 42 Oklahoma 11.3%
Oregon $647 Oregon 53 Oregon 34.3%
Pennsylvania $778 Pennsylvania 59 Pennsylvania 31.1%
Rhode Island $655 Rhode Island 37 Rhode Island 30.2%
South Carolina $646 South Carolina 43 South Carolina 8.22%
South Dakota $591 South Dakota 36 South Dakota 3.2%
Tennessee $655 Tennessee 47 Tennessee 16.1%
Texas $742 Texas 57 Texas 13.0%
Utah $644 Utah 40 Utah 16.5%
Vermont NA Vermont 34 Vermont 1.1%
Virginia $671 Virginia 43 Virginia 8.7%
Washington $644 Washington 47 Washington 19.1%
West Virginia $707 West Virginia 40 West Virginia 6.23%
Wisconsin $618 Wisconsin 46 Wisconsin 18.2%
Wyoming NA Wyoming 35 Wyoming 2.3%

Read Comparison between Medicare Supplement Plans

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