What Is an HMO?

What Is an HMO?

If you're looking for a health plan that's easy to understand, easy to use and easy on your wallet, an HMO may be just what you need for you and your family.

HMO. It’s Simple.

An HMO – or Health Maintenance Organization – keeps costs low and predictable. 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 and hospitals, called your HMO provider network, to help control how much you pay for health care.
  • A primary care physician (PCP) you see for routine check-ups, physicals, colds and flu.
  • Your PCP will refer you to a specialist, if needed, for more serious illnesses.
HMO. 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, medications, lifestyle and how your family health history may affect your health.

Getting Started

When you first sign up for an HMO health plan, you choose, or are assigned, a primary care physician (PCP).

Each person on your plan can pick a PCP. PCPs typically focus on general internal medicine or family medicine. Women and girls can choose an obstetrician/gynecologist (OB/GYN) as their PCP. 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 the front of your member ID card. You can also log in to Blue Access for MembersSM.

Working with Your PCP

Your PCP is your partner in keeping you healthy. Here are some helpful tips for working with 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 right away will help avoid delays when you’re sick or need a referral.
  • Get a referral. If you need to see a specialist or behavioral health care provider, 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 your in-network OB/GYN. You’ll also need a referral to visit a hospital for non-emergency services. You can search Provider Finder® to see who is covered in your network.
  • Call 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’ll either fit you into their schedule or refer you to another doctor or clinic. In some cases, they may have you go to the 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.
Can I Change my PCP?

You can change your PCP at any time, except if you are hospitalized or in the 2nd or 3rd trimester of pregnancy.

HMO. It's Coordinated.

Having one health care expert coordinate all your health care keeps your costs and health on track. An early diagnosis and treatment can prevent many common health issues from getting worse.

Year after year, BCBSMT HMO health plans help improve member health and lower their overall cost of care because health issues are managed before they get serious. People with chronic conditions such as asthma and diabetes often see the greatest results.

HMO. It's Affordable.

HMO health plans control costs through preventive health care that helps you avoid serious and costly health problems. Your costs are also lower because doctors and hospitals in the HMO network agree to offer their services at a set price.

The HMO network may include care and services from:

  • Doctors
  • Hospitals
  • Clinics
  • Pharmacies
  • Labs
  • Imaging centers
  • Medical equipment vendors

In most cases, your HMO health plan won't cover any of your expenses if you go to a provider who isn’t in your network. Here's why: Providers set their own prices for their services. These prices can vary by a few hundred to thousands of dollars for the same service. BCBSMT 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.

How do I know if a provider is in my network?

To make sure a provider is in your plan's network, search Provider Finder®, our online directory. Provider Finder also has a cost estimator to help you figure costs for health visits, procedures, surgeries, diagnostics and imaging, vaccinations and other services.

If you're a BCBSMT member, register for or log in to Blue Access for Members, your secure account access site, for a personalized search based on your health plan and network.

Helpful hint: No matter which type of plan you have, get to know it, what's covered and where you can go for care before you need it. Knowing how your plan works may save you time and money. Learn more about how HMO insurance works.

Originally published 5/23/2022; Revised 2022