HMO Eligibility

Can I sign up for a HMO Plan?

Eligibility for a Medicare HMO Plan does not involve medical screenings or underwriting. Despite the fact that private companies provide these plans, the company cannot reject your application. Anyone who has Medicare Part A and Part B and lives in the service area is able to join the HMO as long as they do not have ESRD.

Eligibility and participation in Medicare Part A AND Part B determine HMO eligibility. To qualify for an HMO Plan an applicant must already have Part A and Part B or be eligible to sign up for both of them during the Initial Enrollment Period.

Medicare HMO Plans are area specific. A person must live within the plan's service area to qualify for an HMO Plan. HMO Plans also rely on specific networks of medical doctors and providers that exist within the service area. If you are seeking care outside of the network or outside of the service area the out-of-pocket expenses will be considerably higher. Each HMO is unique and you will have to look at the plan carefully to determine what is and isn't covered when visiting out of network providers.

ESRD Patients and HMO Eligibility

ESRD stands for End-Stage Renal Disease (kidney failure). Patients diagnosed with ESRD will not be allowed to join a Medicare HMO Plan. Patients that are diagnosed with ESRD while they are plan members can usually keep their HMO coverage if they choose to. In special circumstances exceptions to the ESRD rule exist. For example, successful transplant patients may be able to join an HMO Plan.

HMO Medicare Eligibility for Non-citizens

It is surprising but non-US citizens are eligible for Medicare Benefits and are also eligible to apply for HMO Medicare Plans. They must meet the following rules:

  • Must be a legal US resident 65 years old or older who has resided in the country for at least 5 consecutive years.
  • Residents who have not met the 40-quarter requirement for paying into Social Security will have to pay an additional premium for Part A coverage.

In summary, basic eligibility for a Medicare HMO Plan is determined by eligibility for or enrollment in both Medicare Part A and Part B. The applicant must also live within the plan's service area. People with ESRD are generally excluded from HMO Plans. US residents 65 and older who are eligible for, or have Part A and Part B may also sign up for a Medicare HMO Plan. They must have resided in the United States consecutively for five years to be eligible for Medicare.