A Medicare Health Maintenance Organization, also referred to as an HMO is a government program under the Medicare Advantage Program which is offered to qualified recipients as an alternative to traditional Medicare. At one time there was only the option of Traditional Medicare. Recent changes in Medicare policy has added an HMO to the Medicare Advantage Program which gives individuals a different way of receiving services. To understand fully how HMOs work within Medicare, requires brief explanations of how Medicare and HMOs in general operate.
A government health insurance plan provided to individuals over the age of 65. Medicare consists of four components: hospital coverage (Part A), medical coverage (Part B), Advantage Plans (Part C) and Prescription Plan (D).
HMO’s are managed care organizations that coordinate a person’s health care plan. Health care professionals are required to provide patient care within the requirements of the specific HMO they are contracting with.
An individual who chooses to join a Medicare Advantage plan, such as a HMO must currently have both Part A (hospital coverage) and Part B (medical coverage) policies. In most situations, a qualified person who wishes to join an HMO as part of the Medicare Advantage Plan (Part C) can only do so at certain times of the year.
In most cases, you will be required to receive services from medical professionals that are within the plan’s network. An exception is emergency care or out of area urgent care. Some HMO plans may allow you to choose medical care and services outside of the plan’s network for an additional cost. It is important to make certain that you completely understand all components of your Medical Plan including your Medicare HMO.