What Is an HMO?

An HMO — or health maintenance organization — can help keep your costs lower and more predictable compared to other types of plans. With one doctor to coordinate your care, an HMO health plan is easy to use.

An HMO health plan offers:

• Monthly premiums, copays and deductibles that are often lower than other types of plans.
• Access to certain doctors, hospitals, clinics, pharmacies, labs, and other care and service providers in your HMO network, to help control how much you pay for health care.
• A primary care provider (PCP) you see for annual physicals, preventive screenings, common illness or injuries, and other routine care. A referral from your PCP is required for most other types of care, like seeing a specialist, to be covered by your plan.

It's Personal

An HMO health plan offers personalized care. Your care is coordinated by one doctor who knows you — your health history, current issues, medicines, lifestyle and how your family health history may affect your health.

Get Started

When you first sign up for an HMO health plan, you choose, or are assigned, a PCP who's part of a medical group or independent practice association.

Each person on your plan can pick a PCP. A PCP most often focuses on general internal medicine, family medicine or obstetrics/gynecology (OB/GYN). Older adults can choose a geriatric doctor. Children can have a pediatrician.

If you're a member, you can find your PCP or your medical group listed on your member ID card. You can also log in to your online member account for a personalized search based on your health plan and network.

Your Health Partner

As the primary member of your care team, your PCP plays a big role in helping you  stay healthy. Here are some tips to help you make the most of your PCP:  

• If you're a new patient, see your PCP right away. When you make your first appointment, let the doctor's office know you're a new patient. Going to your new patient appointment right away will help avoid delays in getting an appointment when you’re sick or need a referral.
• Get a referral. If you need to see a specialist, your PCP will refer you to one. Make sure the specialist or behavioral health care provider is in your network. Women don't need a referral to see an in-network OB/GYN. You’ll need a referral to visit a hospital for non-emergency services. To find a provider or hospital in your network, log in to your account and go to Find Care.
• Call your PCP when you need care. Your PCP should be your first stop when you need care. If the office is closed, call the doctor's after-hours number. For common illness and injury, like a cold, flu, minor cuts or burns, they will fit you into their schedule or refer you to another doctor or clinic. In some cases, they may have you go an urgent care clinic or a hospital.
• For emergencies. If your illness or injury is life-threatening, call 911 or go to the nearest emergency room. You don't have to stay in-network or get a referral. Just let your PCP know that you had an emergency as soon as you can. They’ll follow your treatment and manage your follow-up care.

You Have Choices

Finding a provider you feel comfortable with is important. You can change your PCP, medical group or independent practice association to another in-network provider at any time. The only exceptions are when you are hospitalized or in the second or third trimester of pregnancy.

• To change to a different PCP:
  Online
  Log in to your account.
  Choose the “Change PCP” link.
  Follow the instructions.
  By phone
  Call the customer service number on your member ID card.

Having one health care expert coordinate all your health care helps keep your costs and health on track. Year after year, health plans help improve member health and lower their total cost of care because health issues are handled before they get serious.

In most cases, your HMO health plan won't cover your costs if you go to a provider who isn’t in your network. Your health plan contracts with network providers who offer a service at a set price. Because out-of-network providers don't have a contract with us, we can't control how much they charge you. To avoid getting big bills, make sure you stay in your network.

Be Informed

No matter which type of plan you have, review it carefully. Know what's covered and where you can go for care before you need it. Understanding how your plan works may save you time and money.