Plans & Coverage
Medicare HMO Plans
An HMO (Health Maintenance Organization) is a type of Medicare Advantage plan that keeps premiums and copays low by using a defined provider network and, usually, requiring referrals to see specialists. If your doctors are in the network and you don't travel often, an HMO often costs less than the alternatives. You still pay the $202.90 Part B premium in 2026.
How an HMO works
You choose a primary care physician inside the plan's network. That doctor manages your care and refers you to in-network specialists. Because the plan can negotiate hard with a defined set of providers, it can offer lower premiums and copays than a plan with no network at all.
The trade is real: outside the network, except for emergency and urgent care, you generally pay the full cost yourself.
Pros and cons, honestly
| Advantages | Trade-offs |
|---|---|
| Low or $0 plan premium | Out-of-network care generally not covered |
| Predictable, usually lower copays | Referrals often required for specialists |
| Often strong extra benefits (dental, vision, OTC) | Prior authorization for some services |
| Drug coverage usually built in | Networks can change every January |
| A yearly out-of-pocket maximum | Poor fit if you travel or winter out of state |
When an HMO is the right choice
- Your doctors and preferred hospital are already in the network.
- You get your care locally and don't spend months out of state.
- You want the lowest predictable monthly cost.
- The extra benefits are worth real money to you.
- You don't mind a referral step before seeing a specialist.
If any of those don't describe you, compare a PPO or Medigap before deciding.
Checking the network properly
"My doctor takes Medicare" and "my doctor is in this plan's network" are different statements, and only the second one matters on an HMO. Provider directories also go out of date.
We verify each of your doctors and your hospital against the specific plan year before you enroll, and again each fall when networks reset. You can also browse plan options in your county on Medicare Plan Compare.
What it costs
Beyond the plan premium, budget for the Part B premium of $202.90 a month in 2026 (CMS fact sheet), your copays as you use care, and the plan's out-of-pocket maximum as the worst case. Compare that maximum first — it's the number that protects you in a bad year.
Switching if it isn't working
You aren't locked in forever. During the January 1 – March 31 Medicare Advantage Open Enrollment Period you may switch once to another Advantage plan or return to Original Medicare, and the October 15 – December 7 Annual Enrollment Period lets anyone change.
The one caution: returning to Original Medicare doesn't guarantee you a Medigap policy unless you're in a guaranteed-issue situation. Check the Medigap timing rules before you move.
Not sure which of these fits you? A free 15-minute call with a licensed local advisor sorts it out — no pressure, and no cost to you. We do not offer every plan available in your area. For a complete list of every plan in your county, use Medicare Plan Compare or call 1-800-MEDICARE.
Questions, answered
What happens if I see an out-of-network doctor on an HMO?
Except for emergency and urgent care, out-of-network care generally isn't covered on an HMO — you'd pay the full cost. That's why verifying the network before you enroll matters so much.
Do I need a referral to see a specialist?
On most HMOs, yes — your primary care doctor refers you to an in-network specialist. Some HMO-POS variants relax this. We'll tell you which rules your specific plan uses.
Are HMO plans cheaper than PPOs?
Usually on premium and copays, because the network is tighter. Whether they're cheaper for you depends on whether your providers are in network and whether you travel.
What if I'm travelling and get sick?
Emergency and urgent care are covered nationwide on any Medicare Advantage plan, including HMOs. Routine and follow-up care outside the service area generally is not.
Sources
- Medicare.gov — Medicare Advantage health plans
- CMS — 2026 Medicare Parts A & B Premiums and Deductibles
- Medicare.gov — Joining a plan
- Medicare.gov — When to buy a Medigap policy
- Medicare Plan Compare
Figures are for 2026 and come from the official sources above. Plan-specific costs vary by county and carrier — confirm yours on Medicare Plan Compare or with a licensed agent.
Talk to a local Medicare advisor
Free, no pressure — we compare your options for you.
Content reviewed by Brian Penner, Independent Medicare advisor — no pressure.