An HMO plan is a “managed care” plan that contracts with medical providers to set a set amount that they will pay out for care within the plan. Plan members can only use medical providers that are a part of the HMO network, and they will pay less out-of-pocket if they use those providers. In exchange, however, HMO members give up a lot of flexibility. HMOs require their members to select a primary care physician (PCP) and make that doctor their go-to for all of their health care needs. That PCP will decide which specialists you should see, when you should see them, and when you should be treated in a hospital setting. With an HMO, you’re largely required to go through that PCP for all of your health care needs.
Its benefits can include:
- Adult day-care services
- Fitness memberships
- Nutrition programs
- Over-the-counter drugs
- Services and supports for those with chronic conditions
- Transportation to doctor visits
- Wellness programs
Pros And Cons
HMO plans require you to stay within their network for care, unless it’s a medical emergency. Also, If your current doctor isn’t part of the HMO’s network, you’ll need to choose a new primary care doctor.
The benefits of an HMO plan include a low cost out-of-pocket, a low monthly premium, and a relatively easy claim experience. If you are healthy and rarely get sick, then an HMO plan may be a good choice for you. HMOs use networks of medical providers, which keeps costs low because the insurance company has a set amount that they’re willing to pay for each service. HMOs are great for people who are healthy and rarely use medical care—since they don’t go to the doctor often, they’ll have a low out-of-pocket cost each month. HMOs, though, come with a few significant disadvantages