What is a Medicare Advantage HMO-POS?
Key Takeaways
- An HMO-POS (Health Maintenance Organization – Point of Service) plan is a type of Medicare Advantage plan that primarily requires in-network care but offers limited out-of-network coverage at a higher cost.
- Unlike standard HMO plans, HMO-POS provides some flexibility for out-of-network services, though coverage terms and costs vary by plan and insurance provider.
- Key features include reduced costs for in-network care, the need for a primary care physician, and potential referral or prior authorization requirements for out-of-network services.
- HMO-POS plans are a good choice for those who want more provider options than a standard HMO offers while maintaining lower costs compared to PPO plans.
HMO-POS plans are a type of Medicare Advantage insurance structure. An HMO-POS plan requires you to get most of your care from in-network healthcare providers, but it does cover out-of-network care in specific circumstances. Explore the key characteristics of HMO-POS plans, determine whether they fit your needs, and learn how to enroll.
HMO-POS: A Medicare Advantage Plan Type
Private insurance companies sell Medicare Advantage plans as an alternative to Original Medicare. These plans include all Medicare Part A and Part B benefits but usually cover more services than Original Medicare.
With added coverage and flexibility, more beneficiaries opt for private insurance plans over Original Medicare each year. Since 2010, Medicare Advantage enrollment has doubled.
However, because private companies manage these plans, they come with additional considerations. Insurance companies set their own costs, coverage requirements, and limitations on where you receive care. Many insurance companies contract with a specific network of healthcare providers and facilities, negotiating prices for services within their network.
Some plans, HMOs, only pay for in-network care. In these plans, you must use an in-network primary care physician and get specialist referrals. Other plan types, like PPOs, allow you to get out-of-network care at a higher cost, which offers more flexibility than in-network-only coverage.
HMO-POS plans offer a middle ground between these options, but the exact terms depend on your insurance company.
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Understanding the Medicare Advantage HMO-POS
Provider networks are a crucial component of Medicare Advantage plans. Whether you choose a PPO, HMO, PFFS, or HMO-POS, your Medicare Advantage plan type can affect the cost and convenience of getting care.
HMO plans, which stands for Health Maintenance Organization, only cover out-of-network care in an emergency. HMO-POS plans add a “Point of Service” option, which allows some out-of-network care so you don’t have to pay for it entirely out of pocket. You’ll pay a higher copay or coinsurance, but your plan will still contribute.
Key Features of Medicare Advantage HMO-POS Plans
- Reduced cost for in-network care
- Coverage for some out-of-network care, but at a higher cost
- Requires an in-network primary care physician
May need a referral to see a specialist or prior authorization for out-of-network care - Terms and network size vary by plan
Medicare HMO-POS Limitations
The added flexibility of some out-of-network coverage does not mean HMO-POS plans offer as much flexibility as a PPO plan. HMO-POS coverage rules depend on your specific plan and insurance company. For example, some plans require all medical care to be in-network but allow consumers to go out-of-network for dental care only, while others may allow more out-of-network services.
Depending on your plan, you may still need a referral or prior approval to get coverage for out-of-network services. Overall, you still need to get your care within the HMO network for consistent coverage.
Costs for HMO-POS Plans
- Premiums: Some Medicare Advantage plans may charge an additional premium, separate from your Part B premium.
- Deductibles: You must pay a certain amount out of pocket each year on eligible health costs before your plan begins sharing costs through coinsurance. Some Medicare Advantage plans do not have a deductible, so you begin cost-sharing immediately.
- Copays: This is a flat-rate cost for certain services, like $5 to fill a prescription or $10 to see your primary care physician. Your actual copay will vary based on your plan.
- Coinsurance: You may pay a percentage of the cost for your care. For example, your Medicare Advantage plan may pay for 70% of the total service fee, leaving you to cover the remaining 30% of the cost. Coinsurance rates are lower for in-network services.
- Out-of-network fees: HMO-POS plans cover some out-of-network care for a higher fee. Check the plan details to see what specific cases of out-of-network care are covered.
- Out-of-pocket maximums: This is the most you’ll pay for eligible health services. The out-of-pocket maximum is $9,350 in 2025, but some Medicare Advantage plans set lower limits. Once you have reached your plan’s out-of-pocket maximum, your plan covers 100% of your eligible health costs for the rest of the year.
See It in Action
To understand how an HMO-POS plan might work, consider a scenario where you want to visit an out-of-network specialist. Let’s say you noticed a new mole and want to get it checked, but your preferred dermatologist is outside of your Medicare Advantage plan’s network.
If your HMO-POS plan covers out-of-network specialist care, you can still get coverage for using your preferred dermatologist, though it will cost more than an in-network dermatologist. For example, if your usual coinsurance is 20%, you may have to pay 50% for out-of-network services.
Keep in mind that HMO-POS terms vary by plan, insurance company, and location. Your specific plan might require prior approval, or it may only cover certain out-of-network services.
HMO-POS Medicare Advantage Plans vs. Other Networks
HMO-POS | PPO | HMO | PFFS | |
| Average premium | Low | High | Low | High |
| Average network size | Large | Large | Moderate | Large |
| Designated primary care physician | Required | Not required | Required | Not required |
| Referrals to seek specialist care | Required | Not required | Required | Not required |
| Out-of-network care coverage | Partially covered | Partially covered | Not covered | Covered |
Medicare Advantage HMO-POS vs. HMO
HMO plans have many benefits, but they aren’t for everyone. They’re convenient if you live near reputable in-network doctors and hospitals. If you need basic care, you may find an HMO plan easier to navigate since all your appointments, records, and costs are handled within the same network and typically through your designated primary care physician.
Since the plan has already negotiated prices with its providers, you can avoid some coverage obstacles and surprise costs. In addition, HMO plans often have lower premiums, copays, and coinsurance.
On the other hand, HMO-POS plans deliver many of these same benefits with more flexibility. You might prefer this option if you need specialized care, don’t want to limit yourself to the plan’s network, and don’t mind paying extra out-of-network fees. This plan also expands your options if you cannot access in-network providers easily. Read your plan’s terms closely before committing.
Are Medicare Advantage HMO-POS Plans Good For You?
No insurance plan is universally “good” or “bad.” The right choice depends on your individual health needs, budget, location, and preferences. If you want more choice in your healthcare providers or want to stick with your current specialists, an HMO-POS plan might be a good fit.
Of course, this type of plan does not grant a free pass for out-of-network care; you still need to adhere to the plan’s rules and costs.
Enrolling in Medicare Advantage
If you’re considering Medicare Advantage, your first step is understanding how each plan uses networks. Consider your current healthcare needs, and determine if your current providers are in your potential plan’s network. Decide if you want a plan that bundles vision, dental, or prescription drug coverage, or any other specific services that are important to you.
When comparing plans, look past the premium price. Lower-premium plans may have higher deductibles, copays, or coinsurance costs. Look into how the plan handles cost-sharing and out-of-network services. Finally, explore other factors, like the insurance company’s reputation and whether its in-network hospitals have positive reviews.
Medicare Advantage Enrollment Periods
- Initial Enrollment Period: The easiest time to enroll in any Medicare Advantage plan is during your Initial Enrollment Period. If you qualify for Medicare based on age, this period lasts for three months before and three months after your 65th birthday.
- Annual Enrollment Period: You can also switch to a Medicare Advantage HMO-POS plan during the Annual Enrollment Period, which runs from October 15 to December 7. During this time, all parts of Medicare are open for enrollment.
- Medicare Advantage Open Enrollment Period: If you currently have a Medicare Advantage plan, you can make some changes during the Medicare Advantage Open Enrollment Period, which lasts from January 1 to March 31. You can switch between Medicare Advantage plans or drop your private plan for Original Medicare.
Putting It All Together
A Medicare HMO-POS plan requires you to get most of your care from in-network providers but helps pay for some out-of-network care. The flexibility varies by plan, as some plans may limit out-of-network coverage only to specific types of services. If you need help choosing the right Medicare Advantage plan, consider working with a licensed insurance agent or broker.
Sources
Medicare Advantage in 2024: Enrollment Update and Key Trends. KFF.org
Medicare & You 2025. Medicare.gov
10 Reasons Why Medicare Advantage Enrollment is Growing and Why It Matters. KFF.org