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HMO Coverage

Health Maintenance Organization

HMO Coverage2019-01-08T08:20:08+00:00

HMO Explained

An HMO Plan is a Health Maintenance Organization insurance. It is a managed health care and is comparable to one-stop shopping. An HMO utilizes a network of providers, hospitals, laboratories, and physical therapists to provide lower rates for members.

Similar to a PPO (Preferred Provider Organization) in that it utilizes in-network providers, it differs in that is a more individualized focused plan. Members have a primary care provider that oversees the plan of care and directs the healthcare.

Perks of HMO Plans

In an HMO, members do not have to find specialists on their own. They are referred from the primary care provider, and the member’s health information is shared between the doctors without the member having to request any transfer of records.

HMO networks are typically larger than PPO networks which give patients more options to specialists and out-patient help.

Most importantly, HMO health insurance is cheaper than PPO or Comprehensive coverage. Flat designated fees for specific events are used. These fees cover events like prescriptions, doctor’s office appointments, or hospital stays. This provides stability and knowledge of how much an appointment will cost. Payments for more costly treatments, such as surgery, are not required up-front, but are payable after the procedure – and they are usually less expensive than the traditional 80:20 reimbursement.

Points to Notice for HMO Plans

Visiting a doctor out-of-network may provide no benefits or insurance coverage. The entire claim could be denied. Also, getting appointments to see specialists take longer since the primary care provider has to approve the visit first. Second opinions can be more difficult to obtain if you travel out-of-network and are costly.

If your doctor suggests a plan of care that is not covered by an HMO-approved facility, you may not have insurance coverage at the new location.


HMO plans work well for people who want the peace of mind that managed health care brings. The plan’s reduced price is very appealing to many people and should be carefully balanced between options of managed care’s constraints and comforts.

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