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HMO Plans

Health Maintenance Organization (HMO) Plans have lower premiums in return for stricter guidelines. Many HMOs require the beneficiary to stay within their network of providers. They also typically require a primary care physician to be selected, as well as receive referrals from that physician to see a specialist. Only in emergency situations will you be allowed to receive care from outside the plan’s specific network.

Some of the extra coverage and benefits that an HMO Plan can provide includes:

  • Dental, vision, and hearing coverage
  • Prescription drug coverage 
  • Transportation to doctor visits 
  • Adult daycare services
  • Fitness memberships
  • Nutrition programs 
  • Wellness programs 


To first be eligible for an HMO Plan, you must be enrolled in Original Medicare. You cannot drop your Original Medicare coverage, otherwise, you will not be eligible for an HMO Plan.

You can enroll in an HMO Plan during specific enrollment periods:

  • Initial Enrollment Period: The Initial Enrollment Period (IEP) is a seven-month period that starts three months before your 65th birthday month and ends three months after.
  • Annual Election Period: The Annual Election Period (AEP) lets Medicare beneficiaries change their Medicare coverage from October 15 to December 7.
  • Medicare Advantage Open Enrollment Period: The Medicare Advantage Open Enrollment Period starts from January 1 and ends March 31. If you’re already enrolled in a Medicare Advantage Plan, you can use this period to switch to a different MA/MAPD Plan.
  • Special Enrollment Period: The Special Enrollment Period (SEP) gives you the opportunity to sign up for Medicare or switch to a new Medicare plan, but only if you are in a special circumstance.

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To determine whether an HMO or PPO Plan is right for you, you need to be aware of their differences:

  • PPOs offer more flexibility regarding where Medicare beneficiaries can receive care. Many HMOs have restrictions.
  • PPOs are more costly than HMOs.
  • PPOs do not require a primary care doctor or referrals to see specialists.

For more information and HMO Plans and whether it may be right for you, give us a call.