Medicare Advantage HMO-POS (Mistakes to Avoid)

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Some HMO plans comes with a Point-of Service option as well. Traditional HMOs provide care through a network of doctors, specialists, and hospitals available within the plan’s network. In this case, you cannot get care outside the plan’s network. However, with an HMO-POS plan, you can also go outside your plan’s network to get care.

HMO-POS plan is a Medicare Advantage plan that combines both the features of an HMO plan and a POS plan. It is a Health Maintenance Organisation plan that comes with added Point of Service benefits and offers members more flexibility when they need care. The HMO-POS plan gives you added benefits as it makes up for the lapses of both the HMO and POS plans.

HMO Point-of-Service allows you to get some services out-of-network for a higher copayment or coinsurance. It is important for you to abide by the rules of the plan such as getting prior approval for a certain service when needed.

With an HMO Point-of-Service plan, you can get routine health care coverage when you travel out of your network area but you must be within the United States.

Under the HMO benefits plan, you have access to certain doctors and hospitals called your HMO provider network. You get to choose a Primary Care Physician (PCP) from the HMO network that will manage your care. However, you’ll need a referral to see a specialist to receive the HMO benefits.

When opting for an HMO-POS Plan, know that you will:

  • Have to chose a Primary Care Physician to coordinate all your care.
  • Pay more of the bill when you see an out-of-network provider or see a network provider without a referral form or PCP
  • Need to work with your doctor to get prior authorization before you can receive some services.
  • Have a higher deductible or coinsurance costs.
  • Your benefit may cover only part of the cost
  • The HMO and POS portions of the plan have separate deductibles. The care you receive in-network through the HMO has a different deductible than care received out-of-network through the POS plan.

What are the benefits of an HMO-POS Plan?

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Generally, point-of-service (POS) plan offers you more choices than traditional Health Maintenance Organisation (HMO) plan, so having the option of getting both in a single plan leaves you with more choices than would have been obtainable having just one of them.

Firstly, when you join an HMO-POS plan, you generally get healthcare services from doctors, other healthcare providers, or hospitals in the plan’s network (except emergency care, or out-of-area dialysis). Secondly, unlike the traditional HMO plan, you can go out-of-area to get care and coverage for certain healthcare services, though at a higher cost.

Thirdly, the HMO-POS plan provides prescription drug coverage (Part D) but you’ll be required to join an HMO plan that offers Prescription drug coverage (MAPD). It also provides dental, vision and hearing coverage.

Fourthly, it avails you the opportunity of getting routine healthcare services even when you travel out-of-network area because the POS part of the plan enables you get coverage outside your service area.

Lastly, if your doctor or other healthcare provider leaves the plan’s network, your plan will notify you. You may choose another doctor in the plan’s network.

However, despite these benefits you may be required to get a referral to see a specialist in most cases, except for certain services like yearly screening mammograms. Also, you’ll need to follow the plan’s rules, such as getting prior approval for certain services when needed.


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Payment of monthly premiums, medical deductibles and coinsurances may differ depending on the provider network you’re subscribed to. However, there is a limit to your out-of-pocket payment per year.