Questions? Contact Customer Service at (855) 645-8448
A PCP provider is your first point of contact and most likely will be the first to see signs of things like depression, chronic disease or other health concerns. Their job is to make sure you get the right care in a way that fits your needs and values. This could include managing those symptoms or referring you to a specialist when necessary.
Every member is given the opportunity to select a PCP at the time of enrollment; if you do not, one will be selected for you and assigned based on time and distance requirements. You can also call our Customer Service team at (855) 645-8448 and they will assist you with getting your chosen PCP assigned to you in our systems.
All PCP’s are listed in our Provider Directory on our Memorial Hermann Health Plan website in the “Find A” section. You can search by name, zip code or mileage radius. To search for a provider, click here.
Your PCP will be listed on your member ID card, in the bottom of the top left quadrant.
You may change your assigned PCP at any time by calling our Customer Service team at (855) 645-8448 and they can help you make this change. For any PCP changes made after the 1st of the month, the new PCP selection or assignment will be effective the 1st of the following month.
You do not have to obtain a referral from your PCP to make an appointment with a specialist. However, it is strongly recommended that you work with your PCP or discuss your plans to see a specialist with your PCP ahead of time. This way they can help best coordinate your care and share any necessary details with the specialist.
Once you have enrolled in a Memorial Hermann Advantage HMO plan and we have confirmed your enrollment through Centers for Medicare & Medicaid Services, you will typically receive your Memorial Hermann Advantage HMO membership ID card within 10 days of your effective date.
Memorial Hermann Advantage HMO plans cover the same benefits you receive in Original Medicare, as well as additional health benefits like prescription drug coverage, a $0 copay for PCP visits, dental benefits, hearing and vision allowances, fitness benefit, access to telehealth services and more. Benefits and features vary by plan. You are required to use doctors and other health care providers within the Memorial Hermann Advantage HMO Network.
Learn more about the Memorial Hermann Advantage HMO plan and what it covers.
When you are outside the service area and cannot access care from a network provider, our HMO plans will cover urgently needed care that you receive from any provider. In addition, our plan offers coverage for emergency care worldwide whenever you need it. Members are only responsible for the emergency room and or Urgent Care copays.
Memorial Hermann Advantage HMO does not provide coverage for out-of-network general/routine care services. All costs for these services will be the responsibility of the member.
Urgently needed care is a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical care. Urgently needed care may be furnished by in-network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. The unforeseen condition could, for example, be an unforeseen flare-up of a known condition you have.
For Memorial Hermann Advantage HMO, if it is not urgent/emergent services then you are responsible for all costs.
Yes, the plan will pay for covered urgent/emergent care, or renal dialysis. However, you will be responsible for your bill at the time of service, but you may then submit your bill to the Plan for reimbursement minus your copay.
Once you have reached your maximum out-of-pocket costs, you stop paying out of pocket for all covered services except the services with benefit maximums (i.e. hearing aids, eyewear, SNF, and outpatient rehab services).
No, in that circumstance the ER copay is waived when you are admitted to the hospital within 48 hours of the ER visit and you would only be responsible for the inpatient hospital copay amount.
The Coverage Gap, also known as the “Donut Hole”, is reached after meeting your initial coverage limit of $4,130 for 2021 plan year. While in the coverage gap, you pay discounted prices for Memorial Hermann Advantage/Advantage Plus HMO Formulary drug coverage – 25% of the cost of brand name drugs and 25% for generic drugs – until you meet your yearly out-of-pocket maximum drug cost of $6,550 in 2021. Please see below for additional resources:
After your total yearly drug costs reach $6,550 in 2021, you enter the catastrophic coverage phase and will pay either 5% of the cost for each of your drugs (coinsurance), or $3.70 for generic drugs and $9.20 for brand-name drugs (whichever is greater) for the remainder of the year.
Memorial Hermann Advantage HMO plans will pay up to $400 every year toward the cost of hearing aids.
Memorial Hermann Advantage HMO plans will pay up to $200 every year toward the cost of eyeglasses or contact lenses.
Our service area includes Harris, Fort Bend and Montgomery counties. That means all members must live in one of those 3 counties to be eligible for our plan. Our provider network is not limited to these 3 counties, as any provider or hospital that is in our network, anywhere in Greater Houston is "in the network."