What is a Medicare HMO?

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  • Written By: wiseGEEK Writer
  • Edited By: O. Wallace
  • Last Modified Date: 30 December 2018
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One of the options available to people who qualify for Medicare is to participate in private insurance or health care plans that help to increase the amount of care and lower costs. This is sometimes called Medicare Part C or a Medicare Advantage Plan. There are a number of different types of coverage available when participating in a Medicare Advantage Plan, and some people choose coverage through a Medicare HMO or health maintenance organization, which operates very much like HMOs that don’t involve Medicare.

As expected, a Medicare HMO has an organization of doctors or other health providers and facilities that serve its community. People who want their medical costs covered must use these providers and facilities under most ordinary circumstances. The first choice that the person participating in the Medicare HMO must make, then, is choice of a primary care physician (PCP).

Primary care physicians belonging to the Medicare HMO are paid a fee per month by the organization, and for such, they provide what care each patient needs. Instead of the patient paying a percentage of care, as they would with Medicare Part A and Part B, they pay a copayment for all covered services. There may be larger copayments for trips to the emergency room or hospitalizations but the costs are usually lower than the percentage basis under which regular Medicare is paid.


Another part of coverage that is often available through Medicare HMO plans is prescription drug service. This is sometimes called Medicare Part D. As with paying for medical services, people will pay copayments for medications offered by the HMO plan. These are usually generics, and people may have to cover greater or part of the cost of brand name drugs or those used in a non approved fashion.

HMOs save money in part by limiting benefits. While they are likely to cover most major medical services, they limit access to the number of providers or facilities from which a person can receive care. They also make decisions about what will and will not be covered, though the US government, in part, can regulate this.

People considering a Medicare HMO may do so for numerous reasons. They are usually the lowest cost option of Medicare Part C, and they may save money. Other factors should be taken into account, such as whether the HMO contracts with current doctors and what limits they may place on coverage. People can also consider other insurance options to enhance their medical care like belonging to PPO plans instead.



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