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Medicare Advantage HMO-POS Plans
What is Medicare Advantage HMO-POS Plan?
Medicare Advantage HMO-POS (Health Maintenance Organization - Point Of Service) plans are a type of Medicare Advantage plan that combines characteristics of HMO and PPO plans.
They provide a managed care structure where you typically select a primary care physician and get referrals for specialist care, similar to a standard HMO plan.
However, like a PPO plan, HMO-POS plans allow you some flexibility to seek services outside of the plan's network, although at a higher cost.
This "point of service" option gives you the flexibility to see out-of-network providers for certain types of care. It's important to understand the plan's rules and potential costs associated with out-of-network care.
Like other Medicare Advantage plans, HMO-POS plans cover all the benefits of Original Medicare and often include additional benefits such as prescription drug coverage, dental, vision, and hearing care.
Each HMO-POS plan can have different rules and costs, so it's important to review the specifics of any plan before joining.
Eligibility for Medicare Advantage HMO-POS Plan
To be eligible for a Medicare Advantage HMO-POS (Health Maintenance Organization - Point Of Service) plan, you must meet certain criteria:
- Medicare Eligibility: You must be eligible for Medicare, which typically means you are 65 or older, or you are under 65 with a qualifying disability or condition. In the United States, you're usually eligible for Medicare when you turn 65, or you've been receiving Social Security Disability benefits for at least 24 months, or you have End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS, also known as Lou Gehrig's disease).
- Medicare Part A and Part B: You need to be enrolled in both Part A (hospital insurance) and Part B (medical insurance) of Original Medicare.
- Residency: You must live in the service area of the HMO-POS plan you want to join. These plans often have a specific network of doctors and hospitals in a localized area.
- No End-Stage Renal Disease (ESRD): Typically, you can't join a Medicare Advantage plan if you have End-Stage Renal Disease, although there are some exceptions. As of 2021, however, rules have changed to allow more people with ESRD to enroll in Medicare Advantage plans, but it's always best to check with the plan.
- No Other Coverage: You generally can't have other overlapping types of health coverage. For instance, if you're eligible for a group health plan through your employer or a union, you might not be able to join a Medicare Advantage plan.
Enrollment Periods for Medicare Advantage HMO-POS Plans
Medicare has defined several enrollment periods during which you can sign up for, change, or disenroll from these plans:
- Initial Enrollment Period (IEP): This is the seven-month period when you first become eligible for Medicare. It starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. If you're eligible for Medicare due to disability, your IEP starts 3 months before your 25th month of disability and ends 3 months after your 25th month of disability. During this time, you can join a Medicare Advantage Plan.
- Annual Election Period (AEP): Also known as Open Enrollment, it occurs from October 15 to December 7 every year. During this period, you can change from Original Medicare to a Medicare Advantage Plan, switch from one Medicare Advantage Plan to another, or switch back to Original Medicare. If you’re enrolled in a Medicare Advantage Plan, you can also switch to a new Medicare Advantage Plan during this period.
- Medicare Advantage Open Enrollment Period (MA OEP): This occurs from January 1 to March 31 each year. During this time, if you're already enrolled in a Medicare Advantage Plan, you can switch to a different Medicare Advantage Plan or switch back to Original Medicare. If you switch to Original Medicare during this period, you'll have an opportunity to also join a Medicare Prescription Drug Plan.
- Special Enrollment Periods (SEPs): You can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, like if you move or lose other insurance coverage. These chances to make changes are called Special Enrollment Periods. Rules about when you can make changes and the type of changes you can make are different for each SEP.