Medicare Advantage HMO

An HMO is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. When you have an HMO, you generally must get your care and services from doctors, other health care providers, and hospitals in the plan’s network, except:

• Emergency care
• Out-of-area urgent care
• Temporary out-of-area dialysis

Some HMOs are Point-of-Service (HMOPOS) plans that may allow you to get some services out-of-network for a higher copayment or coinsurance. It’s important that you follow the plan’s rules, like getting prior approval for a certain service when the plan requires it.

What else you need to know.

• If you get health care outside the plan’s network, you may have to pay the full cost.
• If your plan gives you prior approval for a treatment, the approval must be valid for as long as the treatment is medically necessary. Also, your plan can’t ask you to get additional approvals for that treatment. If you’re currently receiving treatment and you switch to a new plan, you’ll have at least 90 days before the new plan can ask you to get a new prior approval for your ongoing treatment.
• If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another provider in the plan.
• Your plan can’t charge more than Original Medicare for certain services like chemotherapy, dialysis, and skilled nursing facility care.
• Check with the plan you’re interested in for specific information.

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