Can I Use an out-of-network Primary Care Physician (PCP) If I have a HMO-POS Medicare Advantage plan? If I join an HMO-POS, am I required to use a PCP within the HMO network or can I go out-of-network?
Thanks for all your help with this confusing state of Medicare,
Trish, thank you for your questions!
An HMO-POS spelled out is Health Maintenance Organization Point Of Service.
This means nothing by itself, so let me translate: HMO-POS plans sit somewhere between a traditional Medicare Advantage HMO plan and a PPO. An HMO-POS lets you go outside of the HMO network associated with the Medicare Advantage plan, but only under certain circumstances.
While an HMO-POS is more flexible than a traditional HMO, it’s nowhere near as flexible as a Medicare Advantage PPO plan, especially when it comes to using Primary Care Physicians (PCPs). Of course, Medicare Supplements (Medigap) don’t have networks, really. But that’s a different topic. Let’s roll with just Medicare Advantage plans for this one.
Medicare Advantage HMO PCP Primer
As you’re likely aware, most Medicare Advantage HMOs make you choose and use a primary care provider (PCP) to coordinate your care. In other words, you have to (generally) go to your PCP before being referred on to a specialist or other types of care. You can’t just scroll through the provider directory at your leisure and choose doctors and healthcare providers. Everything is controlled, directed and coordinated by the PCP. Plus, that PCP will also refer you to other in-network providers (except in very rare cases).
If you don’t pick a PCP when you sign up, the Medicare insurance company will choose one for you and assign them to you.
Medicare Advantage PPO PCP Primer
A Medicare Advantage PPO plan does not require you to choose or be assigned a PCP. You can go to doctors and hospitals in and outside of the Medicare insurance company’s preferred network. If you go outside of the network, it’ll usually cost you a lot more money out of your own pocket compared to what it would have if you had stayed in-network. That’s the nice thing about PPOs; the choice is up to you.
Medicare Advantage HMO-POS Primer
HMO-POS plans are pretty rare. They’re hard for the Medicare insurance company to administer, and hard for consumers (like you, Trish!) to understand. I’m surprised you found one.
Under the HMO structure of the HMO-POS, you’d only have access to certain doctors, hospitals, and other healthcare providers in your HMO provider network. You’d still choose a primary care physician (PCP) from the HMO network who will manage your care. Like a regular HMO, you’d still need a referral to see a specialist to receive the HMO benefits.
However, the “POS” portion of the HMO-POS allows for limited flexibility, and this flexibility differs from plan to plan and by Medicare insurance company. The way they’re handled isn’t universal.
Out-Of-Network POS Is a Pain to Deal With Inside Medicare
An HMO-POS allows for out-of-network access. This usually means they allow you to go out-of-network (like a PPO) but usually ONLY for hospitals and specialists. Some HMO-POS plans allow you to see a doctor outside of the network without your PCP referring to them, but not always.
These things can get messy quickly. For instance, if you go out-of-network, you’ll likely have to pay more, just like a PPO. If your in-network PCP referred you for care inside the network, and you chose to go to another provider outside of the network, the claims processing can get nasty. Not only will you have more out-of-pocket to pay because you went out-of-network, but you may only have a portion of your costs covered.
Sometimes, HMO-POS plans allow you to see a PCP outside of the plan’s HMO network, but ONLY if you are outside of the Medicare insurance company’s service area. For you snowbirds (or sunbirds) out there, if you have a PCP in both locations, one will be in-network, and one might be out. Unless the particular Medicare insurance company’s plan service area is in both locations. In that case, one of your PCPs may show up as not covered, or at the very least out-of-network.
Last but not least? Look forward to more paperwork, Trish. If you use the POS part of the HMO-POS, you’ll usually have to file your own claims with the Medicare insurance company to get reimbursed. This means you’ll need to keep track of your receipts.
Should You Buy a Medicare Advantage HMO-POS?
Ugh. See what I mean? It gets messy. Messy for the Medicare insurance company to process and pay claims, and messy for the consumers who bought the HMO-POS. That’s why there aren’t a lot of them around.
My advice? Pick a path and don’t try to get the best of both worlds. If you’re going to enroll in a Medicare Advantage plan, pick an HMO or a PPO. Trying to have your cake and eat it, too, is tough.
If you’re still going to go down the HMO-POS route, make sure you look up something called the Evidence of Coverage and read it. Yes, it’ll make you fall asleep, but it will tell you how the in-network and out-of-network benefits work. Once you’ve gotten an idea from the EOC, call the plan and validate your particular scenario with them.
Make sense? Hope so!
I love answering Medicare questions. Send me yours at email@example.com, and I’ll pick a few for a future blog post!
To your wealth, wisdom, and wellness!
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Author Bio Matt Feret is the author of the Prepare for Medicare book series and launched prepareformedicare.com to help people get objective answers to questions about Medicare. Matt is also the host of The Matt Feret Show. He has held leadership roles at numerous Fortune 500 Medicare health insurers in sales, marketing, operations, product development, and strategy for over two decades.