HMO Plans (Health Maintenance Organizations)

Health Maintenance Organization (HMO) plans are a common type of Medicare Advantage plan structure. These plans generally require members to receive care from providers within a defined network, except in emergency situations.

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How HMO Plans Work

Under an HMO structure, members typically select or are assigned a primary care provider (PCP). Referrals from the primary care provider may be required before seeing specialists, depending on the specific plan design.

Provider Networks

HMO plans operate within defined provider networks. Covered services are generally received from in-network physicians, hospitals, and facilities. Services obtained outside the network may not be covered, except in emergency or urgent care situations.

Cost Structure

HMO plans typically use defined copayment amounts for many services rather than percentage-based coinsurance. Cost-sharing details vary by plan and are outlined in each plan’s Evidence of Coverage (EOC).

Out-of-Pocket Maximum

All Medicare Advantage HMO plans include an annual maximum out-of-pocket limit for Part A and Part B covered services. Once this limit is reached, the plan pays 100% of covered services for the remainder of the plan year.

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Disclaimer: This information is provided for educational purposes only and is based on publicly available guidance from the Centers for Medicare & Medicaid Services (CMS). It has not been reviewed or endorsed by Medicare, CMS, or any federal agency. This content does not constitute plan-specific advice. For individual coverage questions, please consult a licensed insurance professional.