What are disadvantages of HMO?
Answered by 11 licensed agents
Answered by Edward Smith, ChFC, CRPS, AIF on June 30, 2025
Broker Licensed in OH, GA, IN, KY & SC
(Plan C) can have good benefits, and HMO limits your Healthcare to your contracted network.
Their are other Medicare options that have less restrictions like PPO's and /or Medicare Supplements (Medi-Gap).
Many like a Medi-Gap plan because you can go to almost any Doctor in the USA.
Would you prefer that freedom?
When you are younger & healthier the freedom may not seem important. As we grow older, the odds are that we may have greater health issues where would prefer a greater selection of the highest caliber of available doctors. Some may not accept HMO'S or even PPO's.
Daniel Maisel Insurance - Medicare Agency
(909) 319-5324. Www.InsureItDan.com
http://planenroll.com/?purl=yZLgRcNz
Answered by Daniel Maisel on June 30, 2025
Broker Licensed in CA, AZ, MI & NV, OH, TN & WA
Answered by Holt Rushing on June 30, 2025
Broker Licensed in MS, AK, AL & 29 other states
Some HMO plans that have large networks are more stable and have better benefits than PPOs. Again, this is dependent on the plan and the area of the country.
Another potential disadvantage could be having to get referrals to see specialists; however, many HMO plans have removed that requirement, and you can see any in-network physician without a referral. Those plans function very similarly to a PPO.
I hope this helps, but I hope you can see it's not a black-and-white answer!
Answered by Stuart Graham on June 30, 2025
Broker Licensed in GA, AL, LA, MS, SC & TN
So, here's where the complication arises. This has happened to me on many occasions: My prospect gives me 5 names of doctors with certain specialties. Usually two of them are in one network while the remaining three are a part of a different network. Now it is up to you to determine whether it is best to choose the 2 doctors' network vs. the 3 doctors' network? Normally, a patient wants to retain their Primary Care physician and their cardiologist, as an example. So, it becomes necessary for your agent (be sure she/he is experienced enough to guide you in this important comparison)! It is extremely rare in my example for all 5 doctors being in the same network.
The other dilemma with HMO/PPO's are that "Prior Authorization" is a part of both these plans. This is when a doctor has scheduled a test or treatment for you but has failed to receive your Advantage plan's company's approval. This is becoming more and more commonplace these days. Thus, it is imperative for your doctor to get this "advanced approval" or your procedure will be delayed by weeks! The same holds true for a doctor's prescription for an expensive RX. This could require what is called "step therapy" where the insurance company wants you to use a less expensive drug for your treatment. In not having gotten prior authorization, you are deprived of the "better" drug until the "other" cheaper drug has been eliminated.
Answered by Steven Bleicher on July 13, 2025
Broker Licensed in AZ
Answered by Ami Fouts on June 30, 2025
Broker Licensed in NH & ME
Answered by Aaron Lewis on June 30, 2025
Agent Licensed in NJ & NY
Detailed Disadvantages:
Restricted Provider Network:
HMOs require you to use doctors and hospitals within their network. This can be limiting if your preferred doctors are not in the network, or if you travel frequently and need care outside your network's coverage area.
Referral Requirement:
To see a specialist, you typically need a referral from your PCP, which can add extra steps and potentially delay care. This can be frustrating for those who prefer direct access to specialists.
Limited Out-of-Network Coverage:
Out-of-network care is generally not covered by HMOs, except in emergencies, and even then, the definition of "emergency" can be strict. This means you'll be responsible for the full cost of any non-emergency care received outside the network.
Potential for Disrupted Care:
If your PCP leaves the HMO network, you'll need to find a new one, potentially disrupting your established care relationships. This can also happen if your specialist leaves the network.
Increased Cost for Out-of-Network Care:
While HMOs often have lower premiums than other types of plans, the costs associated with out-of-network care can be significantly higher, negating any initial premium savings.
Answered by Fred Manas on June 30, 2025
Agent Licensed in NY, CT, DC & 7 other states
Answered by Vachik Chakhbazian on June 30, 2025
Agent Licensed in CA, AL, AR & 22 other states
Answered by Andrew Kramer on July 22, 2025
Agent Licensed in FL
Answered by Nicolas Cain on July 29, 2025
Agent Licensed in SC
Agents: Share Your Expertise
Have insights or experiences related to this topic? Help others by sharing your knowledge and answering this question.
Seniors: Ask a Question of Your Own
Questions are generally answered within 1 to 3 business days. Receive valuable perspectives from multiple licensed agents and brokers.
Ask a Question