My Coverage Explained

How HMO Insurance Works – Quick Tips Guide

What is HMO?

Don’t shy away from the acronym! It’s simpler than it seems. HMO stands for Health Maintenance Organization. It’s a type of health plan that gives you access to a network of contracting doctors and hospitals, sometimes called “providers”. This group of health care professionals work together to provide you with a full range of covered health care services. It’s different from PPO (Preferred Provider Organization) insurance in a few ways.

HMO Insurance Doctors and Care:

  • When you sign up for an HMO plan, you can choose to select or be assigned a primary care physician (PCP)  from a network of doctors.
  • Your PCP is your first  point of contact for most of your basic health care needs.
  • Women also have the option to select an OB/GYN as their PCP for obstetrical and gynecological care.

If you need to see a specialist or need any special tests, you will first need a referral from your PCP before seeing another doctor. It’s 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.

HMO Cost and Coverage:

  • HMO Insurance plans generally feature lower up-front costs, or premiums, than other types of plans.
  • HMOs usually require copayments. Copayments are the 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 $25 for each office visit.
  • HMO Insurance plans generally provide coverage only when you use doctors, hospitals and specialists that are in your network, as long as you have a referral when needed. If you seek care outside of your network, other than in the case of an emergency or with preauthorization  from your HMO, your care will typically not be covered at all.

HMO Roadmap to savingsKey Things to Remember about HMOs:

  • Stay in Network. Use our Provider Finder  tool to make sure your doctors, specialists and hospitals are in your plan's network to avoid paying out-of-network costs.
  • 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 about your health issues. He or she may refer you to a specialist. Always ask your PCP to choose an in-network specialist and check our Provider Finder  or call the number on the back of your member ID card to confirm.
  • In an emergency — if your injury or illness is serious or life-threatening — don’t wait. Go to the nearest emergency room. For this type of situation, you don't need a referral.

Help and Tools
Whenever you have questions about your HMO plan, use our resources! call the customer service number on the back of your member ID card or  sign up for Blue Access for MembersSM. BAM lets you keep track of your balances, claims status, benefits, coverage details and more.