HMO-POS benefit FAQs

For Medicare Advantage plan members in Illinois and Missouri

What's an HMO-POS plan?

HMO-POS stands for Health Maintenance Organization with a Point of Service option. “Point of Service” means you can use out-of-network providers. HMO-POS plans have HMO features and allow the choice of providers from outside the plan provider network.

Which providers are included in the out-of-network benefit?

We cover all out-of-network providers that accept Medicare and agree to submit a service claim to us. (The majority of providers do accept Medicare. Chiropractors, vision, hearing, and acupuncture providers are examples who may not accept Medicare.)

Please note: Providers that don't contract with us are under no obligation to treat you, except in emergencies. It's important that you confirm — before receiving services — that the out-of-network provider accepts Medicare and will submit a claim to Medica.

How much will I pay to see out-of-network providers?

HMO-POS plans offer lower out-of-pocket costs when using in-network providers and higher out-of-pocket costs when using out-of-network providers.

In most cases, covered services you receive from an out-of-network provider will be subject to out-of-network cost sharing. Here are three exceptions when covered services may be paid at the in-network level:

The plan covers emergency care or urgent services that you get from an out-of-network provider.
If the providers in our network can't provide Medicare-covered benefits, you can get this care from an out-of-network provider. If you get prior authorization from the plan, you'll pay the same as you would pay in-network.
The plan covers kidney dialysis services at a Medicare-certified dialysis facility when you're temporarily outside the plan's service area.

What benefits are covered out-of-network?

All Medicare Parts A and B benefits are covered out-of-network. Benefits that aren't included in Medicare Parts A and B are only covered when you use in-network providers (see chapter 4, section 2.1 of your Evidence of Coverage for information about covered benefits and cost-sharing).

Out-of-network benefits covered:	Out-of-network benefits NOT covered:
PCP and specialist office visits
Labs and outpatient diagnostic procedures	Routine eye exams and eyewear
Preventive services	Routine hearing exams and hearing aids
Outpatient hospital and ambulatory surgery services	Over-the-counter items
Inpatient hospital and skilled nursing facility stays	Fitness benefit (One Pass)
Mental health and substance abuse services	Transportation (Lyft)
Rehabilitation and therapy services	Post-discharge meals (Mom’s Meals)
Part B drugs
Dialysis and kidney education services
Durable medical equipment and prosthetics
Home health agency care
Podiatry
Chiropractic services

Is a referral required to see an out-of-network provider?

We don't require a referral when you get care from out-of-network providers. However, the out-of-network provider may require you to obtain a referral from your primary care provider before they'll provide services under your POS benefit.

Is a prior authorization required to see an out-of-network provider?

Some services always require authorization regardless of whether you get it from an in-network or out-of-network providers. Examples include elective inpatient admissions and outpatient surgery.

Before getting services from out-of-network providers, ask for prior authorization to confirm that the services are covered and medically necessary. (See chapter 3, Section 2.3 of your Evidence of Coverage for information about prior authorization.)

Without prior authorization, we may not cover the service.