How HMO Works – Quick Tips Guide

What is HMO?
Don’t let the acronym scare you! HMO stands for Health Maintenance Organization. It’s a type of health plan that gives you access to certain doctors and hospitals, often called network or contracting doctors and hospitals (sometimes called “providers”). These health care professionals work together to provide you with a full range of covered health care services. It differs from a PPO (Preferred Provider Organization) in a few ways.


HMO Cost and Coverage:

  • HMOs usually feature copayments. Copayments are set amounts (either a dollar amount or a percentage) that you pay at the provider’s office for care. An example of a copayment is $20 for each office visit.
  • HMO Insurance plans generally have lower up-front costs, or premiums, than other types of plans.
  • HMO Insurance plans generally provide coverage only when you use doctors, hospitals and specialists that are in your network and with a referral.

If you look for care outside the network, other than in an emergency or with preauthorization from your HMO, your care typically will not be covered at all.


HMO Insurance Doctors and Care:

  • When you sign up, you select a primary care physician (PCP) from a network of doctors.
  • Your PCP is the first person you contact for most of your basic health care needs.
  • Women can also select an OB/GYN as their PCP for obstetrical and gynecological care.

If you need special tests or need to see a specialist, your PCP will give you a referral to see another doctor. It’s always a good idea to search our Provider Finder to make sure the specialist is in your network. Remember, if the specialist isn’t in your network or if you haven’t received a referral from your PCP, the services won’t be covered.

Key Things to Remember about HMOs:

  • See your primary care physician (PCP) first. Your PCP is your doctor who directs all of your health care.
  • Get a referral. Talk with your PCP first for any health issues. He or she may refer you to a specialist. Ask your PCP to choose an in-network specialist. Check our Provider Finder or call the number on the back of your member ID card to confirm. In an emergency — when your injury or illness is serious or life-threatening — go to the nearest emergency room. You don't need a referral for this type of situation.
  • Stay in Network. Check our Provider Finder to make sure your doctors, specialists and hospitals are in your plan's network to avoid paying out-of-network costs.

Help and Tools
If you have more questions about your HMO, call the customer service number on the back of your member ID card. You can also sign up for Blue Access for MembersSM to keep track of your balances, claims status, benefits, coverage details and more. If you are not yet a member but are considering purchasing an HMO Insurance plan, check out our shopping guide and call our enrollment team with any questions at 800-531-4456.

We’re happy to help!

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