What Is a Medicare Advantage HMO-POS Plan?

If you’ve been shopping Medicare Advantage plans and ran into the term HMO-POS, you’re not alone in wondering what it means. It sounds like alphabet soup — but this hybrid plan type can offer the best of both worlds for people who want low costs and some provider flexibility.

In this article, we’ll discuss how HMO-POS plans work, and how they compare to standard Medicare Advantage HMO and PPO plans.

Key Takeaways

• HMO-POS plans combine the cost benefits of HMO plans with limited PPO flexibility – offering a middle ground for Medicare beneficiaries
• Out-of-network coverage is available but costs significantly more than staying within your plan’s provider network
• These plans work best for frequent travelers and those in limited network areas who need occasional specialist access outside their region
• Premium costs typically fall between traditional HMO and PPO plans, making them attractive for budget-conscious beneficiaries seeking some flexibility
• Extra benefits like vision, dental, and hearing coverage vary significantly by plan and require careful comparison during enrollment

Medicare Advantage enrollment has more than doubled since 2010, with beneficiaries increasingly seeking plans that balance affordability with provider flexibility. HMO-POS plans have emerged as a compelling option for those who want more than a basic HMO offers without jumping to a full PPO’s higher costs.

HMO-POS Plans Combine Network Structure with Out-of-Network Options

A Medicare Advantage HMO-POS (Health Maintenance Organization Point-of-Service) plan functions primarily like a traditional HMO but includes a crucial difference – the ability to access out-of-network providers when needed. This hybrid approach gives beneficiaries a structured, cost-efficient healthcare network while preserving the option to seek care outside that network in specific circumstances.

Unlike traditional HMO plans that strictly require in-network care except for emergencies, HMO-POS plans offer what’s called a “point-of-service” option. This feature allows members to receive covered services from out-of-network providers, though at a higher out-of-pocket cost. Understanding these plan structures helps Medicare beneficiaries make informed decisions about their healthcare coverage options.

The network structure remains the foundation of these plans. Members still benefit from coordinated care through their chosen primary care physician and access to a curated network of specialists and facilities. However, when life circumstances require care outside this network – perhaps due to travel, limited local specialists, or personal preferences – the point-of-service feature provides that flexibility without requiring a plan change.

How HMO-POS Plans Work in Practice

Primary Care Physician Requirements Vary by Plan

Most HMO-POS plans require members to select a primary care physician who serves as the central coordinator for their healthcare needs. This PCP becomes the first point of contact for non-emergency medical issues and typically manages referrals to specialists within the network. However, plan requirements vary significantly, with some offering more flexibility in PCP selection and others maintaining stricter coordination requirements.

The PCP relationship in HMO-POS plans often extends to out-of-network care coordination. When members choose to use the point-of-service option, their PCP may still need to provide referrals or authorizations, depending on the specific plan rules. This maintained coordination helps ensure continuity of care even when accessing providers outside the primary network.

In-Network vs Out-of-Network Coverage Costs

The cost structure of HMO-POS plans creates a clear financial incentive to stay within the network while preserving out-of-network options for necessary situations. In-network services typically follow standard HMO cost-sharing arrangements – often featuring lower copayments, reduced coinsurance rates, and streamlined billing processes.

Out-of-network costs present a different picture entirely. Members using the point-of-service option face significantly higher out-of-pocket expenses, including potentially separate deductibles, higher coinsurance percentages, and additional administrative requirements. In 2025, the in-network out-of-pocket maximum for Medicare Advantage plans caps at $9,350, though many plans set lower limits to provide additional member protection.

These cost differences require careful planning and budgeting. Members should thoroughly review their plan’s Summary of Benefits to understand the specific financial implications of choosing out-of-network care, including whether separate deductibles apply and what percentage of costs they’ll be responsible for covering.

Referral Requirements for Specialists Depend on Plan Rules

Specialist access varies considerably among HMO-POS plans, with some requiring referrals for all specialist care and others providing direct access for certain types of providers. Starting January 1, 2026, UnitedHealthcare Medicare Advantage HMO and HMO-POS plans will require referrals from primary care physicians before accessing certain specialist services.

However, this requirement won’t apply to primary care providers, mental health providers, obstetricians/gynecologists, chiropractors, audiologists, oncologists, hematologists, nuclear medicine, neonatology, emergency medicine, nutrition services, podiatry, optometry, ophthalmology, optician services, radiology, therapeutic radiology, and infectious disease specialists. California, Nevada, and Texas already have referral requirements in place, and existing referral policies in these states will not change.

The referral process for out-of-network specialists typically involves additional steps and documentation. Members may need prior authorization from their plan before accessing out-of-network specialist care, and their PCP often plays a crucial role in justifying the medical necessity for seeking care outside the established network.

Cost Differences: HMO-POS vs PPO and HMO Plans

Premium Positioning Between HMO and PPO Plans

HMO-POS plans typically position themselves in the middle ground between traditional HMO and PPO premium costs. This pricing reflects their hybrid nature – offering more flexibility than standard HMO plans while maintaining lower costs than full PPO coverage. The premium difference can be substantial, making HMO-POS plans attractive for beneficiaries who want some provider flexibility without paying PPO-level monthly costs.

Premium costs vary significantly based on geographic location, plan features, and included benefits. Many HMO-POS plans offer competitive pricing, with some featuring $0 monthly premiums while still providing the point-of-service flexibility. Martin’s Point, for example, offers a 2026 Essential HMO-POS Plan with a $0 premium and added benefits, demonstrating how these plans can deliver value for cost-conscious beneficiaries. This plan includes an out-of-pocket maximum of $9,000 and a prescription drug deductible of $300, though availability is limited to certain counties in Maine.

Out-of-Network Cost Considerations and Payment Methods

The financial reality of using out-of-network services requires careful consideration beyond just higher copayments or coinsurance. Members may face balance billing from out-of-network providers, meaning they could be responsible for the difference between what the provider charges and what the plan pays. This potential financial exposure doesn’t exist with in-network care, where negotiated rates protect members from unexpected bills.

Payment methods for out-of-network care often differ from the streamlined process of in-network services. Members might need to pay providers upfront and then submit claims for reimbursement, creating cash flow challenges and administrative burdens. Understanding these payment processes before needing out-of-network care can prevent surprises and financial strain during medical situations.

Who Benefits Most from HMO-POS Plans

Frequent Travelers Needing Flexible Coverage

HMO-POS plans work well for beneficiaries who travel frequently, whether for leisure, family visits, or seasonal residence changes. The point-of-service feature provides peace of mind for accessing care while away from home, eliminating concerns about being trapped within a limited geographic network. This flexibility proves particularly valuable for snowbirds, RV travelers, and those with family scattered across different states.

The travel benefits extend beyond just emergency care. Routine medical needs, prescription refills, and ongoing specialist care can all be managed through the out-of-network option when necessary, though at higher cost. This capability allows travelers to maintain their healthcare routines without being confined to their home network area.

Those in Limited Network Areas Seeking Specialist Access

Rural and suburban beneficiaries often face limited specialist availability within their local networks. HMO-POS plans provide these members with options for accessing specialized care in larger metropolitan areas or academic medical centers when local options are insufficient. This access can be vital for complex medical conditions requiring subspecialty expertise not available locally.

The ability to access out-of-network specialists becomes particularly important for ongoing conditions requiring continuity of care. Rather than switching plans or accepting limited local options, members can maintain relationships with established specialists while still benefiting from their HMO-POS plan’s coordinated primary care and lower costs for routine services.

Budget-Conscious Beneficiaries Weighing Cost vs Flexibility

HMO-POS plans serve beneficiaries who want to avoid PPO premium costs while maintaining some provider choice flexibility. These plans work well for those who primarily use in-network care but want the security of knowing out-of-network options exist if needed. The lower premiums compared to PPO plans can result in significant annual savings, even factoring in occasional higher out-of-network costs.

This cost-flexibility balance appeals particularly to healthy beneficiaries who don’t anticipate frequent specialist needs but want protection against unexpected medical situations. They can enjoy HMO-level premiums and coordinated care while preserving access to broader provider networks when circumstances require it.

Extra Benefits Beyond Original Medicare

Vision, Dental, and Hearing Coverage Varies by Plan

HMO-POS plans often include supplemental benefits that Original Medicare doesn’t cover, such as routine vision care, dental services, and hearing aids. However, the scope and structure of these benefits vary significantly between plans and insurers. Some plans provide dental coverage both in and out of network, while others limit enhanced benefits to network providers only.

Aetna Medicare Advantage HMO-POS plans, for instance, generally require using in-network providers for medical care but offer flexibility to access licensed dentists either in or out of network for routine dental care. This selective flexibility demonstrates how different benefit categories may have different network requirements within the same plan.

Additional Plan Features Require Careful Review

Beyond basic medical and supplemental benefits, many HMO-POS plans include value-added features like fitness programs, over-the-counter allowances, transportation services, and meal delivery programs. These additional benefits can significantly enhance the overall value proposition but may come with specific terms, limitations, or network requirements.

The availability and scope of extra benefits often influence plan selection as much as medical coverage details. Beneficiaries should carefully review which additional features matter most to their lifestyle and healthcare needs, as these benefits can vary dramatically between similar plans from different insurers.

HMO-POS Plans Offer Affordable Flexibility for Strategic Healthcare Choices

Medicare Advantage HMO-POS plans represent a thoughtful compromise between cost control and provider flexibility, making them suitable for beneficiaries who want more options than traditional HMO plans provide without committing to PPO-level premiums. These plans work best for individuals who can strategically use in-network care for routine needs while preserving out-of-network access for specific situations like travel, specialist care, or geographic limitations.

The success of an HMO-POS plan depends largely on understanding its specific rules, costs, and network adequacy for individual healthcare needs. Beneficiaries should carefully evaluate their typical healthcare utilization patterns, travel habits, and budget constraints when considering these hybrid plans. The key lies in recognizing that while out-of-network flexibility exists, the financial incentives strongly favor staying within the established provider network whenever possible.

Popular Medicare Advantage HMO-POS Plans

If you are considering a Medicare Advantage HMO-POS plan, do your homework. Compare plans. One metric to consider are the number of enrollees. People don’t stay in plans they don’t like.