HMO-POS benefit Q&A's

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In 2021, SSM Health Plan Integrity and SSM Health Plan Harmony include the HMO-POS benefit.

Here are some of the most frequently asked questions about the HMO-POS benefit.

What is 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 characteristics of an HMO and allows 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 claim to us for the services. (The majority of providers do accept Medicare. Examples of providers that may not accept Medicare are chiropractors, vision, hearing, and acupuncture providers.) 

Please note providers that do not contract with us are under no obligation to treat you, except in emergencies. It is important that you confirm - before receiving services - that the out-of-network provider accepts Medicare and will submit a claim to SSM Health Plan.

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

HMO-POS plans offer lower out-of-pocket costs to members when using our in-network providers and higher member 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 urgently needed services that you get from an out-of-network provider.
  • If the providers in our network are unable to provide Medicare-covered benefits, you can get this care from an out-of-network provider. If you obtain prior authorization from the plan, you will pay the same as you would pay in-network.
  • The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plans service area.

What benefits are covered out-of-network?

All Medicare Parts A and B benefits are covered out-of-network. Benefits that are not 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

Preventive and comprehensive dental (Delta Dental)

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 (Silver&Fit)

Mental health and substance abuse services

Transportation (Lyft)

Rehabilitation and therapy services

Post-discharge meals (Mom’s Meals)

Part B drugs

In-home support and companionship (Papa Pals)

Dialysis and kidney education services

Durable medical equipment and prosthetics

Home health agency care


Chiropractic services

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

We do not 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 will 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 receive the service from an in-network or out-of-network provider such as elective inpatient admissions and outpatient surgery. 

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

Without prior authorization, we may not cover the service if we later determine that the service required prior authorization and was not approved.

View our Medicare disclaimer.