{"id":1906,"date":"2016-09-30T17:56:37","date_gmt":"2016-09-30T21:56:37","guid":{"rendered":"https:\/\/singlecare.com\/blog\/?p=1906"},"modified":"2020-07-31T14:55:39","modified_gmt":"2020-07-31T18:55:39","slug":"healthcare-define-hmo","status":"publish","type":"post","link":"https:\/\/www.singlecare.com\/blog\/healthcare-define-hmo\/","title":{"rendered":"What is an HMO?"},"content":{"rendered":"<p><span style=\"font-weight: 400;\">Knowing which health insurance plan to choose can be a tricky decision. Not only do you have to weigh the costs with your health needs, but sometimes the terms and offerings are just plain confusing. In our <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/franchises\/healthcare-defined\/\"><span style=\"font-weight: 400;\">Healthcare Defined series<\/span><\/a><span style=\"font-weight: 400;\">, we try to break down this complex language. Here, we discuss the health plan known as an HMO.<\/span><\/p>\n<h2><span style=\"font-weight: 400;\">What does \u201cHMO\u201d stand for? What does it mean?<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">HMO is an acronym for \u201chealth maintenance organization.\u201d It\u2019s a type of health insurance plan that requires you to use only \u201cin-network\u201d healthcare providers. These are doctors (as well as\u00a0 other medical services like labs and hospitals) that have a contract with your insurance plan. You <\/span><i><span style=\"font-weight: 400;\">can<\/span><\/i><span style=\"font-weight: 400;\"> go to providers outside of your network for medical services, but an HMO plan typically won\u2019t cover the costs unless it\u2019s for emergency care.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">It\u2019s important to note that if you\u2019re having a medical emergency, you should get to the nearest hospital\u2014regardless of whether or not your HMO contracts with it. According to <\/span><a href=\"https:\/\/www.healthcare.gov\/health-care-law-protections\/doctor-choice-emergency-room-access\/\"><span style=\"font-weight: 400;\">healthcare.gov<\/span><\/a><span style=\"font-weight: 400;\">, all plans should help you pay for emergency care, regardless of whether you go to a doctor or hospital within the HMO\u2019s network of providers or not.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">HMOs work like traditional health insurance plans in that you:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">pay a monthly <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/healthcare-premium-defined\/\"><span style=\"font-weight: 400;\">premium<\/span><\/a><span style=\"font-weight: 400;\"> (a recurring fee to have health insurance), and<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">have to pay <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/healthcare-defined-copay\/\"><span style=\"font-weight: 400;\">copays<\/span><\/a><span style=\"font-weight: 400;\"> (set fees you\u2019re charged for services like a doctor\u2019s visit or X-ray), deductibles (the amount you\u2019re required to pay annually before your health insurance starts covering costs), and coinsurance (the percentage of the total cost of care you pay after you\u2019ve met your deductible).<\/span><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">According to <\/span><a href=\"https:\/\/www.healthinsurance.org\/glossary\/health-maintenance-organizations-hmos\/\"><span style=\"font-weight: 400;\">healthinsurance.org,<\/span><\/a><span style=\"font-weight: 400;\"> HMOs have become more popular than many other healthcare plans in the United States since the federal government\u2019s Affordable Care Act (ACA) took effect in 2014. The <\/span><a href=\"https:\/\/reportcard.opa.ca.gov\/rc2007\/hmowhatis.aspx\"><span style=\"font-weight: 400;\">California Office of the Patient Advocate<\/span><\/a><span style=\"font-weight: 400;\"> notes that nearly 50% of California residents are covered by HMOs.<\/span><\/p>\n<h2><span style=\"font-weight: 400;\">How do HMOs work?<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">When you select an HMO for your health insurance plan, you must choose a primary care physician (PCP) within the plan\u2019s network who then coordinates all your medical care. (If the doctor you\u2019ve been using isn\u2019t in the HMO\u2019s network, you may have to choose a new one.) This doctor will take care of your preventive healthcare needs, like your annual checkup, immunizations, and also some routine medical care.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">If you have Medicare, you can choose to get an HMO-style insurance plan through the Medicare Advantage program (also known as Medicare Part C)\u2014as opposed to Original Medicare, which does not use a network of doctors.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">If you need to see a specialist for a medical problem\u2014for example, you\u2019re a runner who tore an ACL\u2014you\u2019ll have to get a referral from your PCP for an in-network provider. If you go without a referral, or decide to see someone <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/healthcare-defined-out-of-network\/\"><span style=\"font-weight: 400;\">out of network<\/span><\/a><span style=\"font-weight: 400;\"> when it\u2019s a non-emergency, you may be responsible for all of the cost of the care that doctor gives you. In addition, women can usually go to an in-network obstetrician\/gynecologist for prenatal and well-woman care without a referral and have the services covered. But still, so you don\u2019t get stuck for care you thought was covered by your health insurance plan, it\u2019s essential that you read your HMO\u2019s plan details and understand exactly what services you\u2019ll be held liable for should you go out of network.\u00a0<\/span><\/p>\n<h2><span style=\"font-weight: 400;\">Why would someone choose an HMO?<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">An HMO is a relatively more restrictive form of health insurance as it limits which doctors it will pay through insurance. If you opt to go out of network, you could get stuck paying the entire cost of that care. But, on the plus side, because you\u2019re more limited, you generally pay less in health insurance premiums for HMOs versus other health plans. That can be a boon for a relatively young, healthy person who typically only accesses health care for preventive care, such as a yearly checkup. In addition to lower health coverage costs, <\/span><a href=\"https:\/\/thrive.kaiserpermanente.org\/thrive-together\/health-care-101\/hmo-vs-ppo-advantages\"><span style=\"font-weight: 400;\">Kaiser Permanente<\/span><\/a><span style=\"font-weight: 400;\"> notes that some of the advantages of HMOs are:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Lower-cost for prescription medicines, and<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Having one doctor who gets to know your medical needs and coordinates all your care.<\/span><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">When cost is more a factor over flexibility, an HMO could be the right health insurance choice for you.<\/span><\/p>\n<h2><span style=\"font-weight: 400;\">What\u2019s the difference between an HMO and PPO?<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">PPO is another acronym\u2014this one stands for \u201cpreferred provider organization.\u201d PPO plans differ from HMO ones in that they allow you to go out of network for care without a referral and without having to pay the full cost when you do so. You don\u2019t even need to select a primary care doctor. While you\u2019ll save money staying with network providers, a PPO will generally pay for at least some of the out-of-network care you receive. For example, your PPO may pay 80% of your medical bill when you visit an in-network provider (and you\u2019ll pay 20%). But when you go out of network, it may only pick up 60% of the cost\u2014leaving you to fork over the cost for 40%. A PPO is an attractive option for people who like their team of doctors and don\u2019t mind paying extra for the freedom of being able to access them when needed. If you have Medicare, PPOs are also available under the Medicare Advantage program.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">For more information, read our article on <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/hmo-vs-ppo\/\"><span style=\"font-weight: 400;\">HMO vs. PPO<\/span><\/a><span style=\"font-weight: 400;\">.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Knowing which health insurance plan to choose can be a tricky decision. Not only do you have to weigh the costs with your health needs, but sometimes the terms and offerings are just plain confusing. In our Healthcare Defined series, we try to break down this complex language. Here, we discuss the health plan known [&hellip;]<\/p>\n","protected":false},"author":15,"featured_media":11558,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[2],"tags":[729,608,691],"coauthors":[8861],"class_list":["post-1906","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-company","tag-doctor-visits","tag-health-insurance","tag-healthcare-costs","franchise-healthcare-defined","wpautop"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.4 (Yoast SEO v27.4) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>What\u2019s an HMO plan, and who is it good for? - The Checkup<\/title>\n<meta name=\"description\" content=\"Health maintenance organizations only cover in-network providers and require referrals from primary care doctors to see specialists. 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