Health Maintenance Organization (HMO)

A cost-conscious choice for you and your employees.

These network-only plans encourage members to get the right care at the right time, which can result in earlier intervention and more cost-effective positive outcomes for you and your employees. In-network care offers employees higher benefits at lower costs.

Members must choose a Primary Care Physician (PCP) to coordinate care and treatment, provide referrals to specialists and facilities. HMO’s have become more flexible in plan design, for example you can buy a HMO that allows members to see specialist without obtaining a referral (Open-Access).

Finding the right care

Here is a summary of benefits and how HMO’s work:


Routine Medical Care
(such as physical exams, mild fever and pains, chronic pain and, headaches, colds and flu):

  • The Primary Care Physician (PCP) will provide medical advice and/or service for a predefined office visit co-payment.


Specialty Care (such as orthopedic or heart disease)

  • The PCP will make an initial assessment and refer the member to a participating specialist if needed.
  • In an Open-Access HMO, the member will seek care from a Specialist without the requirement of a referral from a PCP.
  • All services are subject to a predefined office visit co-payment.


Retail Prescription Drugs

  • Members fill their prescriptions at a participating pharmacy for a predefined office visit co-payment.
  • Members fill their maintenance prescriptions at a participating pharmacy and/or a mail order program for a predefined office visit co-payment.


Hospital Care (such as inpatient care and surgery, or outpatient surgery):

  • For non-emergency care, the PCP and or Specialist will coordinate all hospital care.
  • Services are either covered at 100% or subject to a predefined co-payment.


Emergency Care (such as poisoning, chest pains, broken bones, uncontrolled bleeding, loss of consciousness or sudden paralysis):

  • The employee should go to the nearest emergency facility or call 911, and then call the PCP as soon as reasonably possible, so that he or she can coordinate all follow-up care.

 

Cost Sharing Option (often may refer to services such as inpatient care, outpatient surgery and procedures, radiology and laboratory services):

  • Under this cost-sensitive option, select services are frequently subject to a deductible and coinsurance rather than provided at 100% subject to a co-payment.


Unlike a PPO or POS plan, HMO plans do not provide any out-of-network benefits. Members must receive care, except in the case of a true emergency, from in-network, participating providers.