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.

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, 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 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.

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.

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 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 Members^SM 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 helpful 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 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^® — our online directory — to see who is 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.

You Have Choices

Finding a care 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 exception is if you are hospitalized or in the 2nd or 3rd trimester of pregnancy.

• To change doctors within the same medical group: Search Provider Finder^® to see which care providers are in your network. Then, call the group or association on your member ID card and ask to change doctors.
• To change to a different medical group:
  Online
  Log in to Blue Access for Members
  Choose the “Change PCP” link
  Follow the instructions
  Phone
  Call the customer service number on your member ID card.

Having one health care expert coordinate all your health care keeps your costs and health on track. Year after year, HMO 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 any of your expenses if you go to a provider who isn’t in your network. We contract 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. Learn more about how HMO insurance works.

Originally published 5/23/2022; Revised 2022, 2024