Health Maintenance Organization (HMO) Plan

In most HMO Plans, you can only go to doctors, other health care providers, or hospitals on the plan's list except in an emergency. You may also need to get a referral from your primary care doctor. Find and compare HMO Plans in your area.

Can I get my health care from any doctor, other health care provider, or hospital?

In HMO Plans, you can't get your health care from any doctor, other health care provider, or hospital. You generally must get your care and services from doctors, other health care providers, or hospitals in the plan's network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services, usually for a higher cost. This is called an HMO with a point-of-service (POS) option.

Are prescription drugs covered?

In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want Medicare prescription drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage.

Do I need to choose a primary care doctor?

In most cases, yes, you need to choose a primary care doctor in HMO Plans.

Do I have to get a referral to see a specialist?

In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don't require a referral.

What else do I need to know about this type of plan?

  • If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.
  • If you get health care outside the plan's network, you may have to pay the full cost.
  • It's important that you follow the plan's rules, like getting prior approval for a certain service when needed.