Health Maintenance Organization (HMO)
An HMO is a Medicare Advantage plan type that generally requires you to use in-network providers and choose a primary care doctor, with referrals to see specialists. Out-of-network care is usually covered only in emergencies.
Understanding Health Maintenance Organization (HMO)
A Medicare Advantage HMO (Health Maintenance Organization) is a plan that coordinates your care through a defined network of doctors and hospitals. You usually pick a primary care physician (PCP) who manages your care and provides referrals when you need to see a specialist. Outside of emergencies and urgent care, the plan generally will not cover services you get from out-of-network providers.
For beneficiaries, the trade-off is cost versus flexibility. HMOs often have the lowest premiums — frequently $0 — and predictable copays, plus extras like dental and vision. But you give up freedom: if you see a doctor outside the network without approval, you could pay the full bill yourself. HMOs work best for people who are comfortable staying in-network and want to keep monthly costs low.
For example, if your HMO requires a referral and you visit a dermatologist on your own, the plan may deny the claim and leave you responsible for the entire cost. Confirming your doctors are in-network before enrolling avoids that surprise.
Have questions about HMO plans? Get a free Medicare review and we will check whether your doctors and hospitals are in the plan's network.
Related Terms
Preferred Provider Organization (PPO)
A PPO is a Medicare Advantage plan type that lets you see any provider, with lower costs in-network and higher costs out-of-network. PPOs generally do not require referrals to see specialists.
Provider Network
A provider network is the group of doctors, hospitals, and other providers that contract with a plan. Medicare Advantage plans use networks; staying in-network lowers your costs, while Original Medicare lets you use any provider that accepts Medicare.
Medicare Advantage
Medicare Advantage (Part C) is an alternative to Original Medicare offered by private insurance companies approved by Medicare. These plans include Part A, Part B, and usually Part D coverage in one plan.
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