HMO

What is a HMO?

HMO stands for “Health Maintenance Organization.” HMO insurance plans create networks of providers who receive a specified amount of reimbursement per service.

HMOs allow their members to receive services from any provider within the group. This is an insurance plan that centers your care around a primary care provider (PCP), which means that you will need a referral to see a specialist or therapist. HMO insurance plans place a heavy emphasis on prevention and wellness to increase their members’ health and decrease risk of needing emergency services.

What is a HMO Plan?

HMO insurance plans create networks of providers who receive a specified amount of reimbursement per service; HMOs center your care around a primary care provider, who will need to provide a referral for you to see a specialist or therapist.

How do I know if I have a HMO?

First, check out the name of your insurance plan – this will likely show up on your insurance card. Sometimes, the names of HMO plans have the letters “HMO” in the name. If you don’t see it there, locate your Summary and Benefits, the standardized masterlist of service coverage.

Your Summary and Benefits should have information about the plan near the top, detailing whether your plan is a HMO or another type of insurance. If you still cannot find the answer, give the customer service number on the back of your insurance card a call and ask what type of plan you have.

What are the benefits of a HMO plan?

There are many benefits to having a HMO plan. Here are a few reasons why a HMO plan might be a good fit for you:

• Lower premiums (the amount you have to pay each month to have the insurance). This plan is often more economic than other types of plans (PPOs, POSs) which makes a huge difference in your budget!
• Having a point-person. With your PCP acting as quarterback, your PCP will know what services you receive and be able to follow up with you on your care.
• Having a robust network of providers. HMO plans engage providers across your community and cover their services.

What are the downsides of a HMO plan?

As with any insurance plan, there are downsides that need your consideration. Here are a few to keep in mind:

• Higher out-of-pocket costs. Because the premiums are low, you may have to pay higher copayments (costs per visit) or coinsurance (the amount of the fee for which you’re responsible).
• Needing a referral. With the PCP in charge of what services you need, you may need to visit your PCP more often in order to get specialized care – this sometimes includes therapy!
• Not being able to choose your provider. While there are many providers within each HMO network, with needing a referral comes the risk that your PCP might refer you to a specific provider (and not the person you want to see).
• High costs for out-of-network providers. If you would like to see a provider that’s not in-network with your HMO plan, you will likely have to cover a large portion of the fee yourself.