A Basic Explanation

With an HMO, you’ll probably need to select a primary care physician (PCP). Most HMO plans only cover your care if you see a doctor within the HMO’s network of providers. If you go outside the network, your services might not be covered at all. If you want to see a specialist, you’ll most likely have to get a referral from your PCP.

Expert Advice About HMOs

If you’re considering an HMO, the most important thing to think about is the network. Anytime you want medical care, you’ll need to see someone in your HMO’s network. And some HMO networks can be small. Before you buy an HMO, check to see:

  • Are your favorite providers in-network?
  • Are there network doctors near you?
  • How about hospitals?
  • Specialists?

Unless it’s a true emergency, you may need to stick to these HMO providers for your care. (Many HMOs don’t offer any coverage for out-of-network care.) So make sure your network will meet your needs.

Another thing to consider is that you may need to get a referral from your PCP anytime you want to see a specialist. If you frequently see specialists, this might feel like a hassle. On the other hand, if you rarely need specialists, you might not mind.

A few common HMO myths . . . and the facts

MYTH: HMOs are always cheaper.

FACT: Some HMOs are cheaper, but not all. Because the HMO’s network is often small, it is able to control costs and pass the savings on to you. So you might find some very nicely priced HMO options. In other cases, though, the HMO might cost a lot more than other types of plans. Don’t make assumptions — check your network and your cost carefully.

MYTH: All HMOs have the same benefits.

FACT: There’s lots of variety in HMO plan design. All HMOs are not created equal. When comparing options, you’ll need to take time to go beyond the HMO label to see what’s really in the plan details.

MYTH: HMOs don’t let you choose your doctor.

FACT: With most HMOs you’ll be able to choose your doctor.

When your health insurance goes into effect, you’ll need to choose your primary care physician from within the HMO network. If you don’t have a preference for a PCP, the insurance carrier can help you choose someone. (If you change your mind later, you can switch doctors.)