I signed up for a Medicare Advantage HMO, and I'm wondering if I can see a cardiologist out of network without paying everything myself.

Question

Bill Filer · Accepted Answer

This on can be tricky.

Using an HMO plan typically means you would want to stay within the network in order to keep your costs as low as possible. If you see a doctor outside of the network, you could end up paying the full cost for that care. There could be some exceptions if this was an emergent care issue while out of network. Be careful seeing an out of network doctor on an elective basis.

Some HMO plans are Point of Service (POS). A POS plan may allow you go out of network for some things. If it is a POS plan, you can probably count on paying a higher price if you choose an out of network provider, however. 

Call your plan provider and double check before having the services provided. It's really the only way to know for certain what you're facing. Wish you best!

Melonie Wood · Answer

HMO stands for Health Maintenance Organization and is a type of plan that requires you to see doctors in its network. If you see a doctor outside the network, you will be responsible for all of the costs. The only exceptions to this are medically necessary emergency or urgent care services.

Answered by Melonie Wood on April 12, 2025

Agent Licensed in FL & AL

Answered by Melonie Wood Medicare Insurance Agent

Nikki Rowland · Answer

Medicare Advantage HMO plans generally require you to see doctors within their network to keep costs low. If you visit an out-of-network cardiologist, you may have to pay the full cost yourself unless it's an emergency or urgent care situation.

Some HMO plans have a Point of Service (POS) option, which might allow you to go out of network for certain services, but at a higher cost. Your best bet is to contact your plan provider to confirm whether any exceptions apply to your specific plan.

Ben Washington · Answer

I signed up for a Medicare Advantage HMO, and I'm wondering if I can see a cardiologist out of network without paying everything myself. You can not go out of the network, if you do you will always pay the full cost unless it is emergency.

Answered by Ben Washington on May 1, 2025

Broker Licensed in IL, FL, MN, SC, TX & WI

Answered by Ben Washington Medicare Insurance Agent

Timothy Brown · Answer

Unless there are special circumstances, you are typically required to see in-network providers if you're enrolled in a Medicare Advantage HMO plan.

Diana Garner · Answer

Some HMO plans may allow you to see a specialist out-of-network, but you will have higher out-of-pocket costs. It may all depend on the plans within your area.

I highly recommend sticking with in-network doctors to keep your medical expenses lower. HMO plans typically do not cover any costs for out-of-network doctors.  If you wish to see doctors outside the plan's network, a PPO would be the way to go.

Leslie Helene Sussman · Answer

Generally HMO needs to be IN Network providers.    Contact your carrier to request an approval for Out of Network Specialist.   You must get approval and not always guaranteed.

Dana Dane · Answer

In general, other than emergencies, you must see in-network providers if you are enrolled in Medicare Advantage HMO plan. Please call your agent or your insurance company to fully answer your question.

Answered by Dana Dane on April 3, 2025

Agent Licensed in OR, AZ, CA & 6 other states

Answered by Dana Dane Medicare Insurance Agent

Shelly Hefley · Answer

If you go out of network you would be paying the entire cost. If you would discuss options, please call me - you have a couple of days to make the change. After 4/1/2025 you are stuck on the HMO until 2026

Answered by Shelly Hefley on March 29, 2025

Broker Licensed in IN, AL, IL, KY & TN

Answered by Shelly Hefley Medicare Insurance Agent

Peter Joseph · Answer

You cannot see a cardiologist out of network on a HMO plan. You can on a PPO plan with higher out of pocket costs. You need to have the primary doctor on your HMO plan send in an authorization to see a specialist such as a cardiologist to be covered under that particular HMO plan

Answered by Peter Joseph on April 7, 2025

Broker Licensed in CA, AL, AR & 39 other states

Answered by Peter Joseph Medicare Insurance Agent

Gary Henderson · Answer

Only if it's an HMO POS plan if it's a pure HMO you Cannot see anyone outside the network without having to pay for it yourself

Scott Klag · Answer

Generally, in an HMO you would not be able to see an Out of Network provider without some type of special consideration. You should always check with your agent or your plan to see if there are exceptions.

Answered by Scott Klag on April 21, 2025

Agent Licensed in OH

Answered by Scott Klag Medicare Insurance Agent

Chris Prang · Answer

Not likely. 

You would need your HMO to be a true POS (Point Of Service) HMO that allows you to see out-of-network providers and still have some coverage.

Or, if your HMO doesn't happen to have a cardiologist in the network, then you might be able to get an exception to see an out-of-network one and be covered. This would take a prior approval/authorization from the HMO company.

Or, if your PCP recommends/refers a cardiologist that is out-of-network, and they are willing to go to bat for you and get the insurance company to get that cardiologist approved.

I hope that helps.

Regards,

Chris (The Medicare Analyst)

I signed up for a Medicare Advantage HMO, and I'm wondering if I can see a cardiologist out of network without paying everything myself.

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I signed up for a Medicare Advantage HMO, and I'm wondering if I can see a cardiologist out of network without paying everything myself.

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