Tips for Using Your HMO

There’s a better way to use your health maintenance organization (HMO) plan. Start with your primary care provider (PCP). Your PCP knows how to help you get the health care you need. 

It’s an important relationship, because your PCP knows your: 

• Current health issues and medicines 
• Lifestyle
• Family health history 

Picking a PCP 

Choose your PCP from your health plan’s provider network. You can change your PCP or medical group at any time, except if you are hospitalized. Just let your plan know you want to make a change. 

Your PCP is your partner, working to help keep you healthy. Their office should be your first stop when you need care. Having one provider handle all your health care keeps your costs down and your health on track. If the office is closed, call the provider’s after-hours number. If you have a common sickness or injury (cold, flu, minor cuts or burns) they will fit you in or send you to another doctor or clinic. They may also send you to a hospital if you need urgent care. 

If your sickness or injury is life-threatening, you don’t have to stay in-network or get a referral. Just call 911 or go to the nearest ER. Just let your PCP know that you had an emergency as soon as you can. They will handle any follow-up care you need.

Need a Specialist?

If you need to see a specialist or mental health care provider, your doctor will refer you to one. Make sure the new provider is also in your plan network. Women don’t need a referral to see an in-network woman’s principal health care provider.

Stay In-network 

HMOs use preventive health care to help you avoid serious and costly health problems. Your costs are also lower when you use certain doctors and hospitals. These providers are part of the HMO network. The network may include: 

• Doctors, clinics and hospitals 
• Pharmacies, labs and imaging centers 
• Medical equipment vendors and more 

Using a network helps control how much you pay for care. Your costs will be as low as possible when you see a provider in your network. 

In most cases, an HMO health plan won’t cover any of your costs if you go to a provider that is not in the network. 

Here’s why: Providers set their own prices for services. These prices can differ by a few hundred dollars to thousands of dollars for the same service. HMO plans have contracts with network providers to offer a service at a set price. Because out-of-network providers don’t have a contract with the plan, there’s nothing to control how much they charge you. To avoid big bills, stay in your network. And remember, check your plan to make sure a provider you want to see is in your network. 

Your ID Card Helps 

Your Blue Cross and Blue Shield of Texas member ID card helps you use your benefits. One convenient place lets you check: 

• Your ID number 
• Your plan type 
• Facts on covered services
• Phone numbers you and your doctors will need 

Out-of-network providers are under no obligation to treat Blue Cross Blue Shield Medicare Advantage members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. 

Important Plan Information 
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Originally published 3/26/2019; Revised 2021, 2024