HMO Types

HMO Medicare Plans are generally adapted into a company that already offers HMO Plans to younger people. HMO Plans are structured differently and this directly affects how strict the rules are. It's helpful to know that HMO plans are organized around three basic models. These are:

  • Staff Model HMO
  • Group Model HMO
  • Network Model HMO

Staff Model HMO

A Staff Model HMO is the most limited type of HMO. In this model the providers are directly employed by the HMO. If a patient goes to a provider outside the HMO care generally isn't covered.

Group Model HMO

In the Group Model HMO group practices are hired by the HMO. A patient can then see anyone in the group practice and the care will then be covered. Depending on the size of the group this can be a very flexible model that offers many providers.

Network HMO Model

The most common model is the network model. In this model groups of providers as well as individual doctors sign an agreement with the HMO to provide special rates to their members. They are then part of the provider list.

From a patient's standpoint the network model has the advanatage of possibly allowing you to see most of your current providers under the HMO plan. However, in the network model there is also the most flexibility for providers to join and leave the HMO. Make sure to stay current on which of your providers are covered under your network plan and which are not.

Understanding Medicare HMO Point-of-Service Plans (HMOPOS)

In addition to the basic types of HMO there is another type of Medicare HMO Plan available called HMO Point-of-Service Plans. In these plans some of your services can be obtained from out of network providers but the cost will be higher. In practice an HMOPOS costs more and in return the patient is given greater flexibility in providers. For example, in many HMOPOS plans patients can self refer to in-network specialists. They may pay slightly higher out-of-pocket to do this.

Another benefit is that if the primary care physician suggests a specialist that specialist can often be out of network and the care will be covered. In still other cases patients are allowed to choose an out of network provider and receive partial coverage rather than no coverage as they would under a traditional HMO Plan. For some patients who have one or two providers that are very important to them an HMOPOS plan may be the ideal solution.