Understanding Medicare HMO Plans in New York

Sep 19, 2023

A Medicare HMO (Health Maintenance Organization) plan is an alternative to Original Medicare (Part A and Part B) that is offered by private insurance companies. These plans provide all Medicare benefits, including hospital and medical coverage, but they typically have a network of doctors and healthcare providers that you must choose from. Referrals from a primary care physician are usually required to see a specialist. Additionally, Medicare HMO plans often include prescription drug coverage (Medicare Part D) and may offer additional benefits not covered by Original Medicare, such as vision or dental care.


While Medicare Advantage Plans, especially HMO plans, have been criticized in the past, it’s important to note that these plans have evolved. The old rigid gate-keeper method, which required referrals from primary care doctors to see specialists and limited access to tests and coverage, is no longer the norm. The goal now is to provide a more convenient and comprehensive healthcare experience for beneficiaries.


Medicare HMO Plans  Today Vary Greatly From Plan to Plan Especially Here in New York.

Years ago, consumers were accustomed to needing referrals and staying within a specific provider network. However, HMO plans nowadays are more flexible and often do not require referrals to see specialists. Medicare HMO plans generally offer more comprehensive coverage and have lower out-of-pocket costs compared to PPO plans. In the past, HMO networks were typically smaller than PPO networks, which helped insurance carriers control costs. However, nowadays, many Medicare HMO plans have networks just as large as most PPO plans.

Typically, plans with extensive benefits like dental, vision, hearing, and fitness memberships have smaller provider networks. These benefit-rich plans are often found in heavily populated areas with a high number of Medicare consumers. In all my years as an agent since 2007, I have yet to come across a plan that offers all the bells and whistles, has a low or no premium, and includes a large provider network. Hence, it is crucial to prioritize what matters most to you regarding your coverage when comparing these options.

How Do You Compare Medicare HMO Plans in New York

When advising clients on Medicare HMO plans, we always recommend starting with the basics. In our opinion, the first important factors to consider are the strength of the HMO plan’s provider network and the coverage it provides for prescription drugs. The truth is, most people don’t enjoy visiting doctors, and changing doctors is even less desirable. Therefore, it is crucial to find a plan that covers all of your most important doctors. It’s important to remember that with a

Medicare HMO plan, you are limited to network providers, and going out of network will result in 100% responsibility for your bills, unless it’s an urgent or emergency situation. Since most of us take one or more prescriptions on a daily basis, it is vital to have the most cost-effective drug coverage possible. Once you start evaluating plans based on these criteria, you will likely find that many plans do not meet your medical needs. Generally, having more plans available in your area increases your chances of finding a Medicare HMO plan that covers your doctors and prescriptions, as well as offering extras like dental, vision, and more. We always recommend that you pay attention to a plan’s star ratings as well. You can see all the plans in your zip code by going to Medicare.gov. On Medicare.gov the official Medicare website you can compare plans costs, copays, deductibles as well as star ratings and more all side by side. This website can be a great tool for plan comparisons and general Medicare answers. On the other hand Medicare.gov does not let you know which plans have stronger provider networks, better customer service and reputations with local doctors and hospitals either. It is definitely a good starting place for those who like to educate themselves and gather information.

In Conclusion 

At The Modern Medicare Agency, we understand that choosing the right Medicare insurance plan can be overwhelming. That’s why our dedicated team is here to assist you every step of the way. With our expertise, we help Medicare consumers compare plans effectively, ensuring that all doctors and prescriptions are covered. We also prioritize transparency by informing you about plan rules like step therapy or quantity limits on certain prescription drugs. Additionally, we can provide insight on which plans offer easier prior authorization for tests and procedures. By staying up-to-date on plan membership enrollments, we help you avoid selecting a plan that may have rate or cost share increases. If you’re located in New York, there are excellent Medicare HMO plans available, and we’re more than happy to provide you with a free Medicare coverage review. Contact us today for personalized assistance.

Main Reasons to Choose a Medicare HMO Plan


Comprehensive Coverage  Discover the perfect HMO plan for your health needs with the Modern Medicare Agency. Our comprehensive portfolio options cover medical, dental, vision, and hearing, reducing out-of-pocket risks. Plus, enjoy additional perks like prescription drug coverage and gym memberships. 


Reduced Out-of-Pocket Risks  One of the main advantages of the Medicare Advantage HMO plan is that it reduces out-of-pocket medical risks. This plan covers a wide range of services including doctor visits, hospital stays, lab tests, x-rays, and more. Additionally, with this plan you will have access to a network of providers who accept the plan’s payment terms. This means that you will be able to get the care you need without having to worry about large out-of-pocket costs.


Additional Benefits  In addition to comprehensive coverage for medical needs, the Medicare Advantage HMO plan also offers additional benefits such as prescription drug coverage and coverage for gym memberships. With this plan, you can enjoy peace of mind knowing that your health care needs are taken care of and that you have access to additional benefits that can help improve your overall health and well being.


Customer Support. The Modern Medicare Agency provides year round customer support for their Medicare Advantage HMO plans so that you can get the answers you need when you need them most. Whether it’s questions about eligibility or claims processing or just general information about the plan itself, The Modern Medicare Agency has knowledgeable staff available to provide assistance whenever needed.