Health Maintenance Organization (HMO)

Individuals can enroll in an HMO through an employer, who may cover the entire premium or a portion of it, with the remaining cost deducted from the participating employee’s payroll. Individuals can also enroll in an HMO through the Affordable Care Act Marketplace or as part of their Medicaid plan.

An HMO is a type of managed care health plan where members choose their physician from a network of approved health care providers which typically results in lower premiums and/or copayments. Generally, members of an HMO are only permitted to see a health care specialist (hematologist, cardiologist, rheumatologist) if they request a referral from their primary care physician, also known as a “gatekeeper”. Your designated primary care physician serves as your health care advocate and will help find the best treatment for any physical and mental health problems you might face. HMOs tend to provide the least expensive medical coverage. However, your choice of physicians may be more limited than with a Preferred Provider Organization (PPO) plan.

The benefits of an HMO can differ depending on the company and group plan. Make sure you understand the specific benefits offered by your HMO policy and ask questions if you are confused or unsure about the HMO’s benefits. Be sure to review the Summary Plan Description (SPD), which is the part of the HMO policy that outlines the different benefits provided by your employer or insurance company.