What is a health maintenance organization?

A health maintenance organization (HMO) is defined as either a public or private organization that provides supplemental health care options to its subscribers. The organization contracts with primary care physicians (PCPs), clinics, and specialists to provide care. The HMO and the providers agree on a flat rate of payment between themselves, which allows the HMO to drop premiums for its subscribers. The contracts also allow the organization to provide higher quality care than other health organizations.

It helps to think of a health maintenance organization as a club where you join and you’re assigned to a specific provider. The club has certain rules and regulations for providing coverage. However, as it is like a club, health maintenance organization coverage provides lower costs of non-urgent care. They do this to help you maintain your health. Because, as the adage goes, prevention is worth more than the cure.

What do I need to know about health maintenance organization coverage?

Ask lots of questions when usinghealth maintenance organization coverage

As with any contract, be sure that you are aware of the fine print. Each coverage plan will be a little different depending on the organization and the needs of the applicant. Use the following questions as talking points when inquiring about your specific coverage plan needs:

Here are some answers to frequently asked questions about HMO plans to help you consider if this health plan is right for you.

Can I receive care outside of the plan network?

Under an HMO plan, you must receive care from inside the network.

Do I need to choose a primary care physician (PCP)?

If you choose this type of health insurance plan, you will most likely be required to select a PCP when you sign up. If you need specialized care, you will need to visit your PCP and receive a referral to see a specialist.

Having a PCP is usually very important for many individuals and families. When you have a family doctor, they have the benefit of observing and monitoring conditions more frequently. As you establish a rapport with your PCP, the more time you can save. 

These plans are also typically less expensive than plans that do not have you select a PCP. If you still need help paying for your Medicare coverage, you should ask a health advisor about enrolling in a Medicare Supplement plan.

Are there special enrollment periods for HMOs?

If you qualify for a special enrollment period (SEP) for Medicare, you will qualify for a special enrollment for your HMO. The reason for this is because HMO plans are a part of Medicare. There are a few different ways to qualify for a SEP, but they usually involve certain life changes such as moving.

Additionally, you may qualify for a SEP if you lose insurance coverage or have a chance to change your coverage. So, for instance, if you lose prescription drug coverage, Medicaid, or PACE coverage. On the other hand, if you can sign up for another type of health care coverage, you may also qualify for a SEP.

A senior visiting their PCP to discuss their health coverage

Will my Health Maintenance Organization plan cover urgent care?

Yes. Your plan may even cover some urgent care received out of network. However, it will be your responsibility to learn if the service provider is inside your network or not.

Can I get non-emergency coverage out of the network?

No, all non-emergency care must be received in-network.

How much does an HMO plan cost?

When compared to other Medicare Advantage plans, HMO plans are one of the more affordable options. Out of pocket expenses for these plans are particularly low. The actual premium amounts will depend on what insurance companies offer in your area. However, our experts at Buffalo Health Advisors know how to ask the right questions to get you the best rates.

When can I sign up for an HMO plan?

If you are eligible for Medicare you can enroll in an HMO plan. Typically, if you are over age 65 or are turning 65, you can join any one of these Medicare Advantage plans.

Open enrollment for standard Medicare begins three months before you turn 65. The enrollment period is open for seven months, which includes the month you turn 65 and the three months after.

What is the difference between HMO and PPO plans?

Another plan that resembles the Health Maintenance Organizations is a Preferred Provider Organization (PPO). The main difference between these plans is the range of the network. PPOs reach more physicians than your PCP at no additional cost. You will most likely pay a co-pay determined by your plan, but they will still usually cost more than seeing your PCP.

Other Medicare Advantage Plans

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At Buffalo Health Advisors, we believe in providing solutions to seniors as they transition to Medicare plans. Not only can Medicare Advantage work to protect your health, choosing the right plan can go a long way toward protecting your wealth. This plan is critical if you are going to be living on a fixed income during your retirement years.

It will cost you nothing to learn more about the options available to you. Call or stop by our Nashville, TN office to discuss your Medicare plan options with one of our experienced agents.

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