HMO Plans

The basics

Health Maintenance Organization (HMO) Plans are a type of coverage you can get under Medicare Advantage Plans. These plans offer the benefit of having a lower premium compared to other Medicare Advantage Plans, such as PPO Plans. However, because of the low premium, beneficiaries will have less flexibility when it comes to where they receive their healthcare and if it will be covered.


Pros of having an HMO Plan:

  • You get every benefit that you would from Original Medicare
  • Extra benefits such as hearing, vision, and dental care, which are not covered by Original Medicare
  • Prescription drug coverage; no need to sign up for Medicare Part D separately
  • May offer an annual limit on out-of-pocket expenses. Once paid, you don’t have to pay for any Medicare-covered services for the remainder of the year


Cons of having an HMO Plan:

  • You will likely have to choose a primary care doctor
  • Primary care doctor’s referral may be required before you can see a specialist
  • Out-of-network care not covered

Only in emergency situations will you be able to receive coverage when receiving care outside of the plan’s network. 

When to enroll

If you are eligible for Original Medicare, you are certainly eligible for a Medicare Advantage Plan. You just have to make sure you are enrolling during the proper enrollment periods. Some of the enrollment periods to take note of are:

  • Initial Enrollment Period: The Initial Enrollment Period is a seven-month period that starts your Medicare eligibility. It begins three months before your 65th birthday, and ends three months after. 
  • Annual Enrollment Period: AEP begins on October 15 and ends December 7 of every year. During this period, you have the option to make changes to your Medicare coverage, such as switching from Original Medicare to Medicare Advantage. If you’re currently enrolled in Medicare Advantage, you also have the option to switch to a different Medicare Advantage Plan.
  • Special Enrollment Period: The SEP can be triggered in several ways, but is ultimately unique to the individual’s situation. It is best to speak with a Medicare agent to determine if you do qualify for a SEP, but one of the most common reasons beneficiaries do qualify for this period is because they moved out of their plan’s service area and need a new plan. If you do qualify for this period, you have the option to make changes to your Medicare Advantage Plan, or you switch back to Original Medicare.

For further information about Medicare Advantage and HMO Plans, call me today at (407) 924-8109. You can also email me at