What Are Medicare Advantage HMO-POS Plans?

A Medicare Advantage plan is a type of Medicare coverage offered by private insurance companies and overseen by Medicare. These plans provide Medicare Part A and Part B coverage and may also include Part D prescription drug coverage. Many also include other perks not part of Original Medicare, such as vision, hearing, dental coverage, and other wellness benefits.

A Medicare Advantage HMO plan has an approved network of doctors, facilities, and other healthcare providers who have agreed to provide medical services to plan participants at a discounted rate.

Medicare Advantage HMO plans typically do not cover services provided by doctors, facilities, or other healthcare providers outside the approved network, except in some emergencies. However, a Medicare Advantage HMO-POS combines some features of an HMO with those of a Point-of-Service (POS) plan. This combination allows you to receive coverage for certain out-of-network services, although typically with higher out-of-pocket costs.

Understanding HMO-POS Plans for Medicare Advantage

Medicare Advantage HMO-POS plans are a unique type of HMO plan that can provide extra flexibility by allowing you to receive covered services outside of the plan’s network. Understanding the features of this plan type can help you decide whether it may be appropriate for your needs.

Key Features of Medicare HMO-POS Plans

Reduced cost for in-network care
Coverage for out-of-network care, but at a higher cost
Requires an in-network primary care physician
May require a referral or prior authorization for specialist care and certain services
Network size varies by plan

As with many other types of health insurance, choosing an in-network provider for your HMO-POS plan results in lower costs. However, HMO-POS plans also provide coverage for out-of-network services at a higher cost.

What Do Medicare Advantage HMO-POS Plans Cover?

Medicare Advantage plans are required to provide the same coverage as Original Medicare (Parts A and Part B). These coverages include inpatient hospital care, surgery, lab tests, home healthcare, skilled nursing facilities, hospice care, medically necessary doctor’s visits, tests, durable medical equipment, and other medical care.

Some Medicare Advantage HMO-POS plans also include Medicare Part D prescription drug coverage, but this can vary by plan. It’s also common for HMO-POS plans to provide additional services not covered under Original Medicare, such as vision, hearing, dental, and wellness services.

Medicare Advantage HMO-POS Plans vs. Other Types

Comparing the features of Medicare Advantage HMO-POS plans to other available plan options may assist you in choosing the plan type that fits your needs. Here’s a look at some of the popular plan types and how they differ from an HMO-POS plan.

HMO-POS Plans vs. PPO

A preferred provider organization (PPO)” data-wpil-keyword-link=”linked”>preferred provider organization (PPO) is a type of plan with an extensive network of preferred providers offering services at a discounted rate, much like an HMO-POS. Covered individuals can seek services outside of this network and receive partial coverage. Unlike some HMO-POS plans, PPOs do not require a primary care provider or referrals for specialist care. This additional flexibility comes at a cost, as PPO premiums tend to be higher than the premiums for both HMO and HMO-POS plans.

HMO-POS Plans vs. HMO

A health maintenance organization (HMO) has a moderate-sized network of preferred providers who offer services at a discounted cost. HMO plans typically do not cover out-of-network services except in the case of certain emergencies, while HMO-POS plans cover out-of-network services with a higher out-of-pocket cost.

HMO plans also require you to have a primary care provider and receive referrals for specialist care. While some HMO-POS plans have the same requirement, others do not.

HMO-POS Plans vs. PFFS

A private fee-for-service (PFFS) plan pre-determines how much the plan pays each provider and how much the covered individual is responsible for paying. Some PFFS plans have a network of providers, while others do not have a network at all.

Plan participants can see any provider they choose as long as the provider is eligible to receive payments from Medicare and has agreed to accept the plan’s payment terms and conditions. If a provider is not in the PPFS network, they can refuse to treat a plan participant, except in emergency situations. PPFS plans also do not require a primary care provider or referrals for specialist care.

HMO-POS Plans vs. SNP

A Medicare Advantage Special Needs Plan (SNP) is a special type of plan designed for individuals with certain disabling or chronic conditions or those who are also eligible for Medicaid benefits. SNPs can be organized as an HMO or a PPO, while an HMO-POS plan combines features of both.

Unlike an HMO-POS plan, SNPs also have specific eligibility requirements. In addition, SNPs offer unique coverage options designed to meet the needs of the groups they serve.

HMO-POS Plans vs. MSA

A Medicare Advantage Medical Savings Account (MSA) combines a high-deductible Medicare Advantage plan with a special type of savings account. Medicare deposits a certain amount of money into the savings account each year, and participants can use these funds for healthcare expenses.

The Medicare Advantage plan does not begin to pay until you’ve met your annual deductible, which varies by plan. However, you can use the funds in the savings account to pay for your Medicare-approved costs until you’ve met the deductible. MSAs typically do not have a network of approved providers, allowing participants to seek care from any provider they choose.

Benefits and Drawbacks of Medicare Advantage HMO-POS Plans

A Medicare Advantage HMO-POS can be beneficial for some individuals, but they’re not suitable for everyone. Before you make your decision, consider these essential pros and cons.

Benefits

Affordable premiums: The plan may have lower premiums when compared to other types of Medicare Advantage plans, such as a PPO or PFFS plan.
Out-of-network coverage: You can receive services from out-of-network providers.
Additional coverage: In addition to Medicare Part A and Part B, an HMO-POS plan may include Medicare Part D coverage and additional coverage for services like hearing, vision, and dental, as well as wellness benefits.

Drawbacks

Additional costs: Out-of-network services are typically more expensive than in-network services, with higher copayments and/or coinsurance.
Primary care provider: HMO-POS plans typically require an in-network primary care provider (PCP) to coordinate your healthcare. This can be an advantage, but the extra steps required could be considered a drawback.
Referral requirements: Some plans may require a referral from your PCP to receive specialist care or certain treatments.
Separate deductibles: The HMO and POS portions of the plan may have separate deductibles, which can impact your out-of-pocket costs.

Your Care Network With Medicare Advantage HMO-POS Plans

Medicare Advantage HMO-POS plans typically have an extensive network of preferred providers. Selecting an in-network provider allows you to receive services at a discounted rate, which has been pre-negotiated with the Medicare Advantage plan.

In some cases, it may be necessary to receive services from a doctor, facility, or other provider that is not within the plan’s network. An HMO-POS plan allows you to receive covered services from out-of-network providers, but you may have a higher copayment, coinsurance, or other additional expenses associated with your care.

The Costs of a Medicare Advantage HMO-POS Plan

There are several different types of out-of-pocket costs associated with an HMO-POS plan. This includes:

Premiums: This is the amount you pay for coverage under your Medicare Advantage plan. Premiums are due regardless of whether you receive covered medical care.
Deductibles: This is the amount you must pay before your plan begins to pay for covered expenses. An HMO-POS plan may have separate deductibles for the HMO and POS portions of your coverage.
Copays: These are set dollar amounts you pay for covered services, such as $20 per doctor’s visit.
Coinsurance: This is a pre-determined percentage of your covered medical expenses you’re responsible for paying after you’ve met your deductible. For example, you might pay 20% of your covered medical expenses for each doctor’s visit.
Out-of-network fees: Additional fees may be charged for receiving services from out-of-network providers.
Out-of-pocket maximums: This is the maximum total amount an individual is responsible for paying each year. Once the maximum has been met, you do not pay any additional amount for covered medical expenses (except your premiums) until the next plan year. For 2023, the annual out-of-pocket maximum is $8,300 for approved services, although some plans may have lower maximums.

See It in Action

If you’re covered by a Medicare Advantage HMO-POS plan, and you need to see a specialist, you have two choices: select an in-network provider or a specialist who is not part of the plan’s network. Choosing an out-of-network provider may result in higher costs.

For example, you may have a $20 copayment and a 20% coinsurance for services from an in-network specialist, but this may increase to a $30 copayment and a coinsurance of 25% of your covered costs for an out-of-network specialist. If you had already met your deductible and the bill was $300, your out-of-pocket costs in-network would be $80 ($20 copay plus 20% of $300) or $105 out-of-network ($30 copay plus 25% of $300).

Some plans also have separate deductibles for the HMO and POS portions of the plan. Continuing with the example above, assume you’ve met your HMO deductible but still have $300 remaining on your POS deductible. In this case, when receiving services out of network, you’re responsible for the full $300 cost plus your $30 copay.

How to Select a Medicare Advantage HMO-POS Plan

When choosing a Medicare Advantage HMO-POS plan, it’s important to compare the plan’s costs and features carefully. Here are a few things to consider:

Plan costs: This includes the plan’s monthly premiums, copayments, coinsurance, out-of-network fees, and annual out-of-pocket maximum.
Network size: Consider the network size and the preferred providers’ location.
Preferred providers: Are your preferred doctors, hospitals, and pharmacies within the plan’s network?
Drug coverage: Does the plan you’re considering includes Medicare Part D prescription drug coverage?
Additional benefits: Does the plan offer benefits such as vision, dental, and hearing coverage and wellness benefits, such as gym memberships?
Eligibility: You must be eligible for Medicare Part A and Part B to purchase a Medicare Advantage plan.

Get the Most Out of Medicare HMO-POS Plans

Medicare Advantage plans can change from one year to the next, making monitoring updates that may impact your costs and/or coverage essential. Some of the things to watch for include:

Network changes: Medicare Advantage plans may add or drop providers each plan year. If your preferred providers are no longer part of the plan, this can significantly impact your healthcare costs.
Authorization requirements: Understanding whether you need a referral or pre-approval for specialist care or certain procedures can help you avoid unexpected medical bills.
Annual notice of change: The plan provider is required to send out a notification of changes to participants each plan year. Review it promptly so you can switch plans during the open enrollment period.

Putting It All Together

HMO-POS plans combine the features of an HMO and a PPO. They have a network of preferred providers that have agreed to provide services at a discounted rate, but you can receive services from out-of-network providers at a higher cost.

The premiums for an HMO-POS plan are typically higher than for an HMO but lower than the cost of a PPO. HMO-POS plans also typically require a primary care physician and may require a referral or pre-approval for specialist care and specific treatments.

When comparing HMO-POS plans, it’s important to consider the plan’s cost, the network’s size, and whether your preferred providers are part of the network. It’s also helpful to consider whether the plan includes prescription drug coverage and other benefits. Remember that plans can change each year, so paying attention to updates that may impact you is essential. You may be able to switch plans during the open enrollment period if the one you’ve chosen no longer meets your needs.

An HMO-POS plan allows covered individuals to seek medical services outside the plan’s network. However, out-of-pocket costs, such as copayments and coinsurance, may be higher than the cost of the same service in-network. Out-of-network services may also have a separate deductible.

You cannot have a Medigap policy and any type of Medicare Advantage plan, including an HMO-POS plan, at the same time. When you enroll in a Medicare Advantage plan, you are unenrolled from Original Medicare and cannot use a Medigap plan.

Referral requirements vary by plan. Some plans require you to get a referral from your primary care provider before receiving covered care from a specialist. However, other plans allow you to seek specialist care with no additional requirements. Consult with your plan provider to confirm whether you need a referral before seeking specialist care.

Medicare Advantage HMO-POS Plans: A Comprehensive Overview