HMO-POS vs HMO: Comparing Medicare Advantage plans

August 13, 2020
comparing HMO and HMO-POS Medicare Advantage plans

Healthcare has a language of its own, full of terms and acronyms that can be confusing. At Aspire Health Plan, we want to clear up any confusion as best we can. When looking closer into Medicare Advantage (MA) plans, you may have noticed the acronyms “HMO” or “HMO-POS” following a plan name. These acronyms designate different MA plan types.

  • HMO stands for health maintenance organization
  • POS stands for point oservice

What is a Health Management Organization (HMO) Medicare Advantage plan?

An HMO plan is a type of MA plan. HMOs provide you with the same benefits, protections, and rights as Original Medicare, but with different costs, and rules. HMO plans (such as ones offered by Aspire Health Plan) also offer additional supplemental benefits that you might need such as dental, vision and hearing services. HMO plans require you to have a primary care physician (PCP) who will act as your care coordinator. This ensures your care is in the hands of someone that you know and trust. These plans require that your PCP and specialists they refer you (along with hospitals and other service providers) to be within the HMOs network. If you choose to see a doctor or other provider outside of that network, you will likely be responsible for higher costs. Most MA HMOs offer Medicare Advantage Prescription Drug Plans (MAPD) as part of their plan benefits, including all plans offered by Aspire Health Plan.

How does a Point of Service (POS) Medicare Advantage plan work?

Think of a POS plan as a “hybrid” bringing together elements of an HMO and a Preferred Provider Organization (PPO) plan. If you are in an HMO-POS plan, you must choose an in-network physician as your PCP, but you may go outside of your provider network to receive healthcare services. Just remember that your level of coverage will be better if you stay in-network meaning your cost will be lower if you see in-network providers.

What is an HMO-POS Medicare Advantage plan?

An HMO-POS plan is a type of MA plan, and it stands for Health Maintenance Organization with a point-of-service option. It has a network of providers that members can use to receive care and services, and an HMO-POS plan will require you to select a PCP. However, you are able to use healthcare providers outside the plan’s network for care or services. Deductibles and out-of-pocket maximums will vary for in-network and out-of-network services.

What are the advantages of belonging to an HMO Medicare Advantage plan?

Members of an HMO are required to use hospitals and service providers with the MA plan’s network. But this usually means lower premiums and out-of-pocket costs. In addition, because HMO networks are closed, you do not have to file your own claim.

HMOs will require you to have a PCP, which has many benefits for your overall health and well-being including:

  • Thorough knowledge of your medical history helps with more accurate diagnoses
  • Proactive primary care to help identify health concerns and chronic conditions earlier
  • Better management and control of chronic conditions
  • Referrals to the right specialists to meet your individual needs
  • Continuity and coordination of care between your PCP, specialists, and health plan
  • Better management of prescriptions

HMO MA plans will also offer benefits including dental, vision or hearing, plus additional supplemental benefits such as OTC allowance, transportation, or fitness memberships.

HMO-POS vs. HMO Medicare Advantage Plans

Type of planPCP required?Referral required?Out-of-network carePremium
HMOYesYesNoVaries by MA plan
HMO-POSYesYesYes, but typically costlierVaries by MA plan, but typically higher than an HMO plan

Unlike, many Medicare Advantage plans, Aspire does not require referrals to see a specialist.

How are HMO and HMO-POS Medicare Advantage plans alike?

HMO and HMO-POS plans have a lot of the same features. These include a defined list of providers, known as a network, which members of the plan use for care and services. With HMO plans, you generally must get your care from your provider network, except urgent or emergency care, out-of-area urgent, or out-of-area dialysis. Typically, both HMO and HMO-POS plans require that you select a primary care physician (PCP) in your provider network.

How are HMO and HMO-POS Medicare Advantage plans different?

The major difference between HMO and HMO-POS plans revolves around the plan’s network. An HMO-POS plan’s network allows plan members to see care outside of the HMO network. Note that out-of-network services usually come at a higher cost, but you are still required to choose an in-network PCP that can best coordinate your care. Most HMO-POS plans have higher monthly premiums than HMO plans, but lower co-pays for doctor office visits, specialty care visits, inpatient, and outpatient care and more.

Which Medicare Advantage option is right for me?

Do you travel a lot? If you do a lot of traveling within the U.S. and you want the convenience of having one doctor coordinating all your care, an HMO-POS plan might be right for you. Many people living in Monterey County travel or visit family and friends for extended periods of time, and an HMO-POS plan can offer peace of mind while still having Medicare coverage.

Aspire Health Plan offers two HMO and one HMO-POS Medicare Advantage plan. For all of our plans, any urgent or emergency care that arises within the U.S. or its territories is covered, and you do not need to obtain authorization prior to seeking care. Members can receive care at any hospital in Monterey County: Community Hospital of the Monterey PeninsulaSalinas Valley Memorial Healthcare SystemNatividad Medical Center or Mee Memorial Hospital. You can head over to the Plans & rates section of our website to learn more information, use our plan comparison tool and get an overview benefit highlights.

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