What is an HMO? An HMO is a health maintenance organization where doctors, hospitals and other health care providers contract with the health plan to form medical groups that deliver health care services to members residing in its service area. HMO members select providers from within those medical groups to get the maximum coverage available through the health plan. They are required to select a primary care physician (PCP), who coordinates their care.

Primary Care Physicians A Primary Care Physician (PCP) provides routine services, coordinates health care services, and provides referrals to specialists and for hospital services. PCPs can be family practitioners, general practitioners, internal medicine practitioners or pediatricians. Claims Process Under an HMO, providers bill the health plan for covered services. Members usually pay a co-pay for services within their medical group. If they use providers or services outside of their medical group, no coverage will be provided and they will be responsible for payment in full for the non-network services (excluding emergency services and out-of-area urgent care). Out of Network Referrals Your insurance carrier's networks are comprehensive, including most recognized specialties. If there is not a particular type of specialty in the network/medical group, authorization may be given to be referred out-of-network. A member’s PCP would contact the patient management department to pre-certify the referral. Treatment from a non-participating provider will be authorized, if the treatment and/or services are not available in network. Non-participating Providers HMO members cannot self-refer to non-participating providers with the exception of emergency services and out-of-area urgent care.