How HMO Insurance Works – Quick Tips Guide

Millions of people have an HMO health plan. Yet, plenty of them are still a little fuzzy about what that really means. 

HMO stands for Health Maintenance Organization. It’s a type of health plan that gives you access to a network of doctors and hospitals, often called providers. This group of health care professionals work together to provide you with a full range of covered health care services. HMO is different from PPO (Preferred Provider Organization) insurance in a few ways.

HMO Doctors and Care

When you sign up for an HMO plan, you first choose to select or be assigned a primary care physician (PCP) from a network of doctors.

• Your PCP is your first point of contact for most of your basic health care needs.
• Women also have the option to select an OB/GYN as their PCP for obstetrical and gynecological care.

If you need to see a specialist or need any special tests, you will need a referral from your PCP before seeing another doctor. You can use the Provider Finder search tool to make sure the specialist is in your network. To access the tool, log in to your Blue Access for Members^SM (BAM^SM) account and click Find Care in the top navigation menu.

Remember, if the specialist isn’t in your network, or if you haven’t received a referral from your PCP, the services won’t be covered.

HMO Cost and Coverage

HMO plans:

• Generally feature lower up-front costs, or premiums, than other types of plans.
• Usually require a copay. Copays are set amounts (either a dollar amount or a percentage) you pay at the provider’s office for care.
• HMO plans generally provide coverage only when you use doctors, hospitals and specialists that are in your plan’s network and approved with a referral when needed. If you seek care outside your network, your care likely won’t be covered at all. Exceptions include emergency care and care that receives prior authorization from your HMO.

Key Things to Remember about HMOs

An HMO is a good choice for a lot of reasons. Making sure you follow HMO rules will make sure you get the most of benefits:

• Stay in network. Use our Provider Finder tool to make sure your doctors, specialists and hospitals are in your plan's network. You’ll avoid paying out-of-network costs.
• See your PCP first. Your PCP is the doctor who directs all your health care.
• Get a referral. Talk with your PCP about your health issues. Your PCP may refer you to a specialist. Always ask your PCP to choose an in-network specialist. Check Provider Finder or call the number on your member ID card to confirm.
• Act fast in an emergency. If your injury or illness is serious or life-threatening, don’t wait. Go to the nearest emergency room. A referral isn’t needed for emergency medical care.

Help and Tools

Whenever you have questions about your HMO plan, use our handy resources. Sign up for Blue Access for Members^SM (BAM) or call the customer service number listed on your member ID card. BAM lets you keep track of your balances, claims status, benefits, coverage details and more.

If you’re not a member yet but are considering buying an HMO Insurance plan, check out our shopping guide.

Originally published 10/7/2014; Revised 2021, 2022