A Health Maintenance Organization (HMO) plan has a network that includes a limited number of doctors, hospitals and other health care providers, usually in a designated part of the state.
As long as you get care from these network providers, you’re covered under the specifics of your plan. If you get care from outside of the network, you’ll have to pay out-of-pocket for all costs. This means you’ll need to make sure your primary care physician (PCP), any specialists you see and any clinics or hospitals where you receive care are in-network to avoid paying extra.
There’s a specific type of HMO plan called a “narrow network” plan. Similar to a regular HMO, these plans have a very limited network of providers, often specific to a geographical region or hospital system. These plans typically cost less, but will ha limited number of in-network providers so be sure to review your options before selecting this type of plan.
An HMO Point of Service (HMO-POS) plan allows you to go outside of the limited network for care. However, you may have to pay more when using out-of-network providers. This means you’ll want to make sure your primary care physician (PCP) and any specialists you see are in-network to avoid paying more for care. With an HMO-POS plan you may also need to obtain prior authorization to receive certain services, whether going in- or out-of-network.
POS plans are best for those who want to have an in-network PCP, but also want to be able to go out-of-network for additional care. Keep in mind, a plan can be considered a POS plan if it offers at least one benefit out-of-network, so be sure to check your specific coverage before receiving out-of-network care to avoid possibly paying more.
PriorityMedicare Key, an HMO-POS plan from Priority Health, is the most popular Medicare Advantage plan in the state.1
A Preferred Provider Organization (PPO) plan allows you to see in-network or out-of-network doctors, however, you will likely pay less for in-network care. With a PPO you’re also able to see a specialist without a referral. Depending on the plan, you will either have an in-network deductible or a combined in- and out-of-network deductible.
Why does staying in network matter?
It’s very important to make sure the providers you see are part of your plan’s network. If your plan has a specified network, you’ll pay less for care and services that come from a provider in that network. Likewise, if you receive care from an out-of-network provider, you may pay more. In some cases, such as with an HMO, you may be responsible for the entire cost of care you receive outside of your network.
If you have questions about Medicare, our Medicare Learning Center has tons of helpful information to help you choose the best plan for your health care needs.
1 October 2023 data reflects processing between 8/05/2023 and 09/08/2023 as reported by CMS.