Medicare HMOs

Updated Oct 17, 20261 min read

Definition

A Medicare HMO is a Medicare Advantage plan structured as a health maintenance organization. Members generally must use the plan's network of doctors and hospitals, except in emergencies, and usually choose a primary care provider who coordinates their care and refers them to specialists. HMOs are the most common type of Medicare Advantage plan.

Medicare HMOs are private plans that contract with Medicare to provide benefits. Members typically use the plan's network, with a primary care provider (PCP) who manages their care and makes specialist referrals.

What are the key features of Medicare HMOs?

Network rules: most services must come from in-network providers
Referrals: members usually need a PCP referral to see a specialist
Emergency exceptions: emergency and urgently needed care is covered out of network

How do Medicare HMOs control costs?

They manage a network of contracted providers, coordinate care through the PCP and emphasize prevention. In exchange for less choice, members often pay lower premiums and cost sharing than in other Medicare Advantage plans such as PPOs.

How do Medicare HMOs differ from other Medicare plans?

Original Medicare lets members see any provider that accepts Medicare. Medicare HMOs limit coverage to the network except in emergencies. Medicare PPOs also cover out-of-network care, at a higher cost.

What Medicare HMOs mean for teams selling into healthcare

Medicare HMOs depend on coordinated care, so they buy care management, network management and member engagement tools, and they work closely with the medical groups in their network. Many of those groups take on financial risk for HMO members, which makes them buyers of population health tools too.