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.

Answered by 24 licensed agents

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!

Answered by Bill Filer on March 28, 2025

Agent Licensed in MO, GA, KS & TN

Answered by Bill Filer Medicare Insurance Agent
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
You would simply need to call your HMO and find out. It is likely that you will pay out of network charges if you choose to get care outside of your HMO network although there can be exceptions made if you are specifically referred to a Dr outside of the network.

Answered by Mark Maliwauki on May 23, 2025

Broker Licensed in ID, AZ, CA & 15 other states

Answered by Mark Maliwauki Medicare Insurance Agent
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.

Answered by Nikki Rowland on May 7, 2025

Broker Licensed in SC & NC

Answered by Nikki Rowland Medicare Insurance Agent
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
With a Medicare Advantage HMO plan, you typically need to use a network of doctors and specialists to receive covered services. If you want to see an out-of-network cardiologist, you may have to pay the full cost of the visit yourself, as HMO plans usually do not cover out-of-network care except in emergencies.

However, some plans may have specific exceptions or allow for out-of-network referrals under certain circumstances. It's best to check your specific plan details or contact your insurance provider directly to understand your options and any potential costs involved.

Answered by Michael Ryan on May 14, 2025

Broker Licensed in CA, AZ, CO & 7 other states

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

Answered by Timothy Brown on April 13, 2025

Broker Licensed in PA, CT, DE & 15 other states

Answered by Timothy Brown Medicare Insurance Agent
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.

Answered by Diana Garner on April 24, 2025

Broker Licensed in KY, FL, IN, OH & TN

Answered by Diana Garner Medicare Insurance Agent
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.

Answered by Leslie Helene Sussman on March 31, 2025

Broker Licensed in NJ, FL & PA

Answered by Leslie Helene Sussman Medicare Insurance Agent
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
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
It depends on the policy you enrolled in but normally out of network doctors will not be covered by an HMO. There are exceptions based on someone’s individual situation and you should ask your carrier if you could get one.

Answered by James Stang on May 17, 2025

Agent Licensed in OH

Answered by James Stang Medicare Insurance Agent
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
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 Fred Manas on May 14, 2025

Agent Licensed in NY, CT, DC & 7 other states

Answered by Fred Manas Medicare Insurance Agent
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

Answered by Gary Henderson on April 14, 2025

Agent Licensed in TX, AK, AL & 46 other states

Answered by Gary Henderson Medicare Insurance Agent
You can see any provider you want as a cash paying patient.

That choice is between and the doctor you want to see

Answered by Marcie Barnes on May 22, 2025

Agent Licensed in TX, AK, AL & 48 other states

Answered by Marcie Barnes Medicare Insurance Agent
Review your summary of benefits for your HMO plan. Out of network usually requires a referral from your primary care physician to see a specialist. Out of network will usually require greater out of pocket expense.

Answered by Donnie Vermillion on May 12, 2025

Broker Licensed in TX

Answered by Donnie Vermillion Medicare Insurance Agent
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)

Answered by Chris Prang on April 28, 2025

Broker Licensed in VA, AZ, CA & 13 other states

Answered by Chris Prang Medicare Insurance Agent
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
no you cannot, unless the plan allows an exemption. In this situation, you more than likely would have to see a cardiologist within the HMO network without having to pay everything out of pocket.

Answered by Nicolas Johnson on May 28, 2025

Agent Licensed in WI & IA

Answered by Nicolas Johnson Medicare Insurance Agent
If you're enrolled in a Medicare Advantage HMO plan, your ability to see an out-of-network cardiologist without incurring full out-of-pocket costs is generally limited. HMO plans typically require you to use healthcare providers within their network for non-emergency services. Visiting an out-of-network specialist without prior authorization often means you'll be responsible for the entire cost of care.

Answered by Alaina Hunt on June 2, 2025

Agent Licensed in KS & MO

Answered by Alaina Hunt Medicare Insurance Agent
With a Medicare Advantage HMO, you typically need to see providers within the plan’s network. Seeing an out-of-network cardiologist usually means you’ll pay the full cost unless it’s an emergency. It’s best to check with your plan directly for any exceptions.

Answered by Carl-Daniel Cole on May 21, 2025

Broker Licensed in MO, AL, AR & 23 other states

Answered by Carl-Daniel Cole Medicare Insurance Agent
1. Always check your Statement of Benefits first.

2. Some HMO plans may allow "out-of-network" services. But most do not.

Answered by Vernon Pate on June 2, 2025

Broker Licensed in AR, MO & OK

Answered by Vernon Pate Medicare Insurance Agent
It seems that you already are aware that HMOs require that you stay in network. The only exceptions to this are for urgent care, emergencies, or in certain cases where your insurance company has pre-authorized the out of network provider. Even so, out of network providers can balance bill, so you may still end up paying a substantial part of the cost. For more freedom to choose that cardiologist, change to a PPO at the next open enrollment unless you have a qualifying event that opens you to a special enrollment.

Answered by Barbara Hawes on May 19, 2025

Broker Licensed in NJ, AZ, CT & 18 other states

Answered by Barbara Hawes Medicare Insurance Agent

Tags: Medicare Advantage

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