{"id":20682,"date":"2019-01-11T09:00:18","date_gmt":"2019-01-11T14:00:18","guid":{"rendered":"http:\/\/www.carecloud.com\/continuum\/?p=20682"},"modified":"2025-10-23T14:10:42","modified_gmt":"2025-10-23T14:10:42","slug":"health-maintenance-organization-hmo","status":"publish","type":"post","link":"https:\/\/carecloud.com\/continuum\/health-maintenance-organization-hmo\/","title":{"rendered":"What is a Health Maintenance Organization (HMO)"},"content":{"rendered":"<p><span style=\"font-weight: 400;\">Navigating the world of health insurance can feel like you\u2019re playing a game of Alphabet Soup. There are several healthcare plan options available. Let\u2019s discuss Health Maintenance Organizations. \u00a0<\/span><\/p>\n<h2><span style=\"font-weight: 400;\">What is a Health Maintenance Organization (HMO)? <\/span><\/h2>\n<p><span style=\"font-weight: 400;\">An HMO is a type of insurance plan. HMOs typically limit coverage to care from doctors, hospitals and other healthcare providers who work for or are contracted by the HMO. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">HMOs usually do not cover out of network care, with a few exceptions such as: <\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Emergency Care<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Out of Area Urgent Care<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Out of Area Dialysis <\/span><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">Some plans, called an HMO with a point-of-service (POS) option, allow you to go out-of-network for certain services. However, it usually costs less if you\u2019re cared for by a network provider. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">For some HMO plans, you\u2019ll need to choose a primary doctor and will have to get a referral to see a specialist. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">HMOs usually provide integrated care and encourage prevention and wellness. So for certain services, such as yearly mammogram screenings, referrals are not required. <\/span><\/p>\n<h2><span style=\"font-weight: 400;\">Prescription Benefits with HMO Plans<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">In many cases, prescription drugs are covered under HMO plans, just be sure to check your specific plan. If you are looking to have <\/span><span style=\"font-weight: 400;\">Medicare prescription drug coverage (Part D)<\/span><span style=\"font-weight: 400;\">, you\u2019ll have to join an Insurance Plan (HMO, PPO, POS,etc.) that offers creditable prescription drug coverage. <\/span><\/p>\n<h2><span style=\"font-weight: 400;\">What\u2019s the Difference Between an HMO and a PPO Plan? <\/span><\/h2>\n<p><span style=\"font-weight: 400;\">While searching for an insurance plan, you\u2019ll likely notice some are HMOs, and others are PPOs. You may want to know what each plan type is and what the differences are. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">PPO stands for Preferred Provider Organization. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">These health insurance plans both use a network of doctors, hospitals and other health care professionals to care for you. The difference is how you interact with the networks. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">Under a traditional HMO plan, you choose one primary care physician (PCP). All your health care services go through that one doctor. You\u2019ll need a referral to see another health care professional, except for an emergency. Visits to health care professionals not in your network will likely not be covered by your HMO. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">Let\u2019s say you have a horrible ear infection. Instead of heading to an ENT, you\u2019d need to see your primary care physician (PCP) first. If they are unable to get the infection cleared up, they\u2019ll refer you to an ENT in the network. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">One exception is that women don\u2019t need a referral to see an in-network obstetrician\/gynecologist (OB\/GYN) for routine care such as Pap tests, annual well-woman checks, and obstetrical care. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">By coordinating your health care through one physician, your PCP, health care costs are lowered for everyone as there are less administrative costs. \u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">PPO plans allow you to see any health care professional you want, regardless of if they are in or out-of-network. Of course, staying within your network means you\u2019ll have smaller co-pays and full coverage once your annual deductibles are met. If you do choose to go out-of-network, you\u2019ll have higher out-of-pocket costs, and not all services may be covered. <\/span><\/p>\n<h2><span style=\"font-weight: 400;\">What Else Should I Know about HMOs? \u00a0<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">Here are a few more important details to know about HMOs: <\/span><\/p>\n<ul>\n<li><span style=\"font-weight: 400;\">If a health care professional chooses to leave the network, \u00a0your plan will let you know. You\u2019ll be able to pick another doctor in the network. \u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">It\u2019s vital to follow the plan rules, such as obtaining prior approval for services if needed. <\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">If you receive health care outside the network, you\u2019ll likely end up paying the full cost.<\/span><\/li>\n<\/ul>\n<p><span style=\"display: none;\" data-sumome-listbuilder-embed-id=\"63167955acecc7c017d1349e21976b34c69d1681cdcbe88c9a25211c5006fd11\">DUMMYTEXT<\/span><\/p>\n<p><strong>Sources: <\/strong><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><a href=\"https:\/\/www.healthcare.gov\/glossary\/health-maintenance-organization-hmo\/\"><span style=\"font-weight: 400;\">https:\/\/www.healthcare.gov\/glossary\/health-maintenance-organization-hmo\/<\/span><\/a><\/li>\n<li><a href=\"https:\/\/www.bcbsm.com\/index\/health-insurance-help\/faqs\/topics\/how-health-insurance-works\/difference-hmo-ppo.html\"><span style=\"font-weight: 400;\">https:\/\/www.bcbsm.com\/index\/health-insurance-help\/faqs\/topics\/how-health-insurance-works\/difference-hmo-ppo.html<\/span><\/a><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Navigating the world of health insurance can feel like you\u2019re playing a game of Alphabet Soup. There are several healthcare plan options available. Let\u2019s discuss Health Maintenance Organizations. \u00a0 What is a Health Maintenance Organization (HMO)? An HMO is a type of insurance plan. HMOs typically limit coverage to care from doctors, hospitals and other [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":43614,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[389],"tags":[],"class_list":["post-20682","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-resources"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>What is a Health Maintenance Organization (HMO)? - Continuum<\/title>\n<meta name=\"description\" content=\"HMO is a type of insurance plan. 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