How HMO Insurance Works – Quick Tips Guide

Millions of people have an HMO health plan. Yet, plenty of them are still a little fuzzy about what that really means. After all, three letters grouped together make a nice acronym, but don’t tell us much about what it is or how it works.

Don’t worry. We’re going to break it all down.

HMO stands for Health Maintenance Organization. It’s a type of health plan that gives you access to a network of doctors and hospitals, often called “providers.” This group of health care professionals work together to provide you with a full range of covered health care services. HMO is different from PPO (Preferred Provider Organization) insurance in a few ways.

HMO Doctors and Care

• When you sign up for an HMO plan, you first 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 a women's primary health care provider (WPHCP) as their PCP for obstetrical and gynecological care.

If you need to see a specialist or need any special tests, you will need a referral from your PCP before seeing another doctor. 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 a copay. Copays are set amounts (either a dollar amount or a percentage) you pay at the provider’s office for care. An example of a copay is $25 for each office visit.
• HMO plans generally provide coverage only when you use doctors, hospitals and specialists that are in your network or approved with a referral when needed. If you seek care outside your network, your care will typically not be covered at all. Exceptions include emergency care and care that receives prior authorization from your HMO.

Key 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. By doing so, you will avoid paying out-of-network costs.
• See your PCP first. Your PCP is the doctor who directs all 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. Check our Provider Finder or call the number on the back of your member ID card to confirm.
• Act fast in an emergency. If your injury or illness is serious or life-threatening, don’t wait. Go to the nearest emergency room. A referral isn’t needed for emergency medical care.

Help and Tools

Whenever you have questions about your HMO plan, use our handy resources. Sign up for Blue Access for Members^SM (BAM) or call the customer service number listed on your member ID card. It lets you keep track of your balances, claims status, benefits, coverage details and more.

If you’re not a member yet, but are considering buying an HMO Insurance plan, check out our shopping guide.

Originally published 11/4/2014; Revised 2021, 2022