NYC Health Insurance: What is an HMO Plan? (Health Maintenance Organization)

Health Care is extremely important for New Yorkers right now, making it even more important to understand the terminology, in order to be as informed as possible about what the doctor or insurance plan is trying to sell you. This week let’s take a look at understanding the “HMO”.

You might hear people refer to some health plans as HMO, which stands for Health Maintenance Organization. HMOs have their own network of doctors, hospitals and healthcare providers.   These provides have agreed to accept payment at a certain level for any services they provide. This allows the HMO to keep costs in check for its members.

In most HMO Plans, you generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network. You may also need to get a referral from your primary care doctor.

Can I get my health care from any doctor, other health care provider, or hospital?

In HMO Plans, you generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network, except:

  • Emergency care
  • Out-of-area urgent care
  • Out-of-area dialysis

In some plans, you may be able to go out-of-network for certain services, but it usually costs less if you get your care from a network provider. This is called an HMO with a point-of-service (POS) option.

Are prescription drugs covered?

In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want Medicare prescription drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage.

Do I need to choose a primary care doctor?

In most cases, yes, you need to choose a primary care doctor in HMO Plans.

Do I have to get a referral to see a specialist?

In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don’t require a referral.

What else do I need to know about this type of plan?

  • If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.
  • If you get health care outside the plan’s network, you may have to pay the full cost.
  • It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.

Find and compare HMO Plans in your area.