A Health Maintenance Organization (HMO) is a type of managed healthcare plan that provides medical services to members through a network of doctors, hospitals, and other healthcare providers. HMOs require members to choose a primary care physician (PCP) who acts as a gatekeeper to coordinate care and provide referrals to specialists within the network. HMOs typically emphasize preventive care and cost control by requiring members to use in-network providers and obtain referrals before specialist visits. They often have lower premiums and out-of-pocket costs compared to other plans but offer less flexibility in choosing providers.
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Key Facts
- Network-Based Care: Members must use doctors and hospitals within the HMO network for coverage, except in emergencies.
- Primary Care Physician (PCP): Members select a PCP who manages their overall care and provides referrals to specialists.
- Cost Structure: Usually lower premiums and co-pays but limited out-of-network coverage.
- Emphasis on Prevention: Focuses on preventive care and early intervention to reduce overall healthcare costs.
- Geographic Restrictions: HMOs often limit coverage to specific geographic areas or regions.
1. What is an HMO health plan?
An HMO is a managed care plan where you get medical services from a network of providers and must choose a primary care doctor to coordinate your care.
2. Do I need a referral to see a specialist with an HMO?
Yes, in most HMOs you must get a referral from your primary care physician to see a specialist.
3. Can I see doctors outside the HMO network?
Generally, no - except in emergencies or urgent care situations. Out-of-network care is usually not covered or costs much more.
4. What are the advantages of an HMO?
HMOs typically have lower premiums and out-of-pocket costs, emphasize preventive care, and provide coordinated care through your PCP.
5. What are the disadvantages of an HMO?
Limited choice of providers and specialists, requirements for referrals, and less flexibility in where you can receive care.
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