HMO (Health Maintenance Organizations)

Under an HMO plan you usually have to obtain your care and services from doctors, hospitals, and other Health Care providers in the plan’s network. In case of emergency care, or out of area urgent care and dialysis, you may obtain services from non-network providers. Some plans provide out of network benefits, but you will bear the major costs for those services.  Plans that offer this option are often referred to as an HMO with a point of service (POS) option. Most HMOs have embedded drug coverage; however, not all of them do.  Before enrolling in an MA Plan, know if it includes prescription drug coverage.

 

Under an HMO you must use a primary care doctor, and obtain a referral to see a specialist. It is important to note that any doctor or specialist can leave the network at any time. If your doctor or other Health Care provider does leave the network, it is the responsibility of the plan to alert you.  If this happens, you will have to choose a different doctor within the plan’s network.  If you decide to continue obtaining medical services from the same care provider after he/she has left the network, you may have to pay the full cost. Each plan has its own set of rules, it’s important that you follow those rules. One such rule is that an authorization must be obtained for a certain service when needed.