Health Maintenance Organizations

Health Maintenance Organizations (HMO)

A Health Maintenance Organization (HMO) is a type of health insurance plan. In most HMOs your clients can only go to the hospitals, doctors, and other health care providers that have agreements with the plan except in an emergency. Your clients may also need to get a referral from their primary care doctor before seeing a specialist.

Can my clients get their health care from any doctor, other health care provider, or hospital?

  • In HMO Plans, they can’t get their health care from any doctor, other health care provider, or hospital. They generally must get their care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, they may be able to go out-of-network for certain services, usually for a higher cost. This is called an HMO with a point-of-service (POS) option.

Are prescription drugs covered?

  • In most cases, prescription drugs are covered in HMO Plans. If clients want Medicare prescription drug coverage (Part D), they must join an HMO Plan that offers prescription drug coverage.

Do clients need to choose a primary care doctor?

  • In most cases, yes, your clients need to choose a primary care doctor in HMO Plans.

Do clients have to get a referral to see a specialist?

  • In most cases they have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don’t require a referral.

What else do my clients need to know about this type of plan?

  • If their doctor or other health care provider leaves the plan, their plan will notify them. They can choose another doctor in the plan.
  • If they get health care outside the plan’s network, they may have to pay the full cost.
  • It’s important that they follow the plan’s rules, like getting prior approval for a certain service when needed.