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

Mark Maliwauki · Answer

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

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

Michael Ryan · Answer

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.

James ONeal · Answer

Generally, Medicare Advantage HMO plans require you to see doctors and other healthcare providers within their network to receive covered services, except for emergencies and urgent care situations. 

If you see a cardiologist who is not in your HMO's network, you may have to pay the full cost of the visit yourself.

Cole Amador · Answer

The answer is usually no, you can't see an out of network cardiologist without paying everything yourself. Out of network will not cover the visit unless it's an emergency or urgent situation. If you go out of network without those exceptions, you will like pay the full cost for that visit.

Answered by Cole Amador on June 16, 2025

Broker Licensed in LA

Answered by Cole Amador Medicare Insurance Agent

Steven Bleicher · Answer

Unless you need an immediate visit to a cardiologist, during the upcoming fall Annual Open Enrollment period, you can very easily change over to another Advantage plan. This is known as a PPO or a Preferred Provider Organization. This will become effective on 1/1/26. It allows you to go both IN & OUT of your network though the “out” visit will be a greater copay cost to you. However, if you are “concerned” about your heart, don’t wait! See that specialist now!

Answered by Steven Bleicher on June 13, 2025

Broker Licensed in AZ

Answered by Steven Bleicher 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

Barbara Barnes, CMIP® · Answer

No. When you have an HMO, there is no coverage for out-of-network providers except in emergency situations. 

At the next Annual Enrollment Period, look for a plan that either includes all the doctors you want to see or a PPO so that you have out-of-network coverage. In the meantime, if you want to see that provider, ask if they have a cash discount and be prepared to transition to an in-network doctor if you need anything more than just a check-up.

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

James Stang · Answer

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

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 & 37 other states

Answered by Peter Joseph Medicare Insurance Agent

Fred Manas · Answer

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.

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

Marcie Barnes · Answer

You can see any provider you want as a cash paying patient.

That choice is between and the doctor you want to see

Rodolfo Rojas · Answer

Hello, unfortunately with HMO, you will have to get a referral from your primary care to go to an in - network provider. 
If you go out of network, you will have to cover the cost yourself, unless it is an emergency. 
how long have you been with this HMO?

Donnie Vermillion · Answer

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

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

Sophia Davis · Answer

Typically, with an HMO, you are responsible for all costs when using out of network services. Some exceptions may be made in certain circumstances. You can each out to the carrier and request a "Network Exception". There are no guarantees, but it's an option.

Answered by Sophia Davis on June 16, 2025

Broker Licensed in OH & PA

Answered by Sophia Davis 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)

Nicolas Johnson · Answer

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.

Alaina Hunt · Answer

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

Kip Nussbaum · Answer

An Advantage HMO will require that you must get all of your services from in network providers. If you want the ability to see providers that are out of network and still have it be covered, but generally at a higher cost to you than and HMO, you will need to select an Advantage PPO plan instead. The downside of the PPO plans are that generally the copays and cost shares are higher, along with the annual maximum out of pocket. They tend to also have smaller allowances for extra benefits such as dental, vision, hearing, OTC, etc.

Answered by Kip Nussbaum on June 18, 2025

Broker Licensed in OH

Answered by Kip Nussbaum Medicare Insurance Agent

Carl-Daniel Cole · Answer

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

Vernon Pate · Answer

1. Always check your Statement of Benefits first.

2. Some HMO plans may allow "out-of-network" services. But most do not.

Barbara Hawes · Answer

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

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.

Agents: Share Your Expertise

Seniors: Ask a Question of Your Own

Related Questions

Agent Locator

Medicare Agents Hub
A non-government resource website

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.

Agents: Share Your Expertise

Seniors: Ask a Question of Your Own

Related Questions

Agent Locator

Medicare Agents HubA non-government resource website

Medicare Agents Hub
A non-government resource website