HMO without Prescription Drugs

A Medicare HMO Plan is a Medicare Advantage Plan where a private insurance company provides your Medicare Part A and Part B benefits. In a Medicare HMO Plan, you can get Medical Services only from the providers who are in the plan's network. You cannot access services outside the network except in cases where you need urgent or emergency care. Premiums will vary depending on the plans available in your area. Depending on the plans available in your area, some of the plans may include Dental, Vision, Hearing, Gym Memberships. Additionally, plans will include a Maximum out of Pocket which would put a cap on your financial exposure in a calendar year. This option would not include a Medicare Prescription Drug benefit.

Is this option right for me?

• If you have other supplementary coverage for Prescription Drug coverage (for example, VA Drug benefits), this could be a good choice.
• If you enjoy value added benefits, like hearing, vision, dental, gym memberships, this could be a good choice.
• If you like having care coordination services to assist you with a chronic condition, this could be a good choice.
• If you prefer a lower fixed monthly premium with higher cost sharing when you need to access benefits to a higher fixed monthly premium with lower cost sharing, this could be a good choice.
• If you are looking for the highest level of value from your Medicare choice and you are willing to accept the restrictions of an HMO network (there are no restrictions in case of urgent or emergency care), this could be a good choice.
• If you are very satisfied with the Provider network for your basic and extended healthcare needs, this could be a good choice.

Advantages

• Financial Exposure to Part A and Part B cost-sharing is capped with a maximum out of pocket. The actual cap depends on the specifics of the plans in your area.
• Premium can be lower than a Medicare Supplement depending on the specifics of the plans in your area.
• Generally, because of the network restrictions, HMO's tend to offer the highest level of benefits relative to premium.
• Additional Value Added benefits may be available (like Dental, Vision, Hearing and Gym benefits) depending on the specifics of the plans in your area.
• Not having a Medicare Prescription Drug benefit means that the premium you pay will generally be less than a plan which would include the drug benefits.

Disadvantages

• Out of Pocket costs will depend on your level of utilization of services in the Medicare HMO Plan subject to a maximum out of pocket.
• Medicare Advantage plans are not Guaranteed Renewable like Medicare Supplement plans. In addition, the benefits can be changed on a calendar year basis.
• No ability to use "out of network" providers (there are no restrictions in case of urgent or emergency care).
• Unlimited financial exposure for Part D Prescription Drug expenses.
• Late Enrollment Penalty would apply for Medicare Prescription Drug benefit unless there is other Creditable coverage.

Costs — Medical and Hospital

• Premium for the Medicare HMO plan will vary based on the county of your residence and the plan you choose to enroll in.
• Generally, there is cost sharing for Hospitalization, Doctor Office visits, diagnostic tests, x-ray, therapy, etc. You will need to review the Summary of Benefits for each of the specific plans in your area to determine the exact out of pocket costs.
• Plans include a Maximum out of Pocket limit which is a calendar year maximum. The actual cap depends on the specifics of the plans in your area.