What does it means to join a Medicare HMO? 

A Medicare HMO (Health Maintenance Organization) is a type of Medicare Advantage (MA) plan. Beneficiaries who enroll in an HMO (or any other MA plan) are choosing to leave or "disenroll" from Original Medicare. HMOs typically use referral protocols and prior authorization procedures as conditions of payment for many procedures and services. These procedures do not exist in Original Medicare. In addition, an HMO:

• sets its own procedures and deadlines for providers to submit claims;
• makes coverage and payment decisions (as opposed to the Fiscal Intermediary or Carrier under Original Medicare);
• sends explanations of benefits, denials, and other notices;
• receives and reviews requests for Reconsideration;
• may or may not have network facilities in the enrollees immediate vicinity; and
• an make annual changes in its network providers, benefits and cost-sharing charges.

For more information, please refer to HAP's chart, The Highlights: Medicare Advantage - Private Fee-for-Service Plans and HAP's fact sheet, Types of Medicare Advantage Plans.

(Back to Medicare Advantage: Enrollment)