Health Maintenance Organization (HMO)
A health plan that requires you to use in-network providers and get referrals for specialists.
What is Health Maintenance Organization (HMO)?
A Health Maintenance Organization (HMO) is a type of health insurance plan that emphasizes coordinated care through a network of providers. You must choose a primary care physician (PCP) who manages your care and provides referrals to see specialists.
HMOs generally have lower premiums and predictable costs, but less flexibility than PPOs. Except for emergencies, you typically won't have coverage for out-of-network care. Your PCP acts as a gatekeeper, coordinating your care and deciding when specialist referrals are appropriate.
Some HMOs are structured as HDHPs and allow HSA contributions, though this is less common than with PPO plans. If considering an HMO for HSA purposes, verify it meets HDHP deductible and out-of-pocket requirements.
Frequently Asked Questions
Can I see a specialist without a referral in an HMO?
Generally no. You need a referral from your primary care physician to see a specialist, except for emergencies.
What happens if I go out of network with an HMO?
Except for emergencies, you'll likely pay the full cost yourself. HMOs typically don't cover out-of-network care.
Are HMOs cheaper than PPOs?
Usually yes. HMOs have lower premiums and often lower out-of-pocket costs, but less flexibility in choosing providers.
Related Terms
Preferred Provider Organization (PPO)
A health plan that offers flexibility to see any doctor, with lower costs when you use in-network providers.
Exclusive Provider Organization (EPO)
A health plan that requires in-network care like an HMO but doesn't require referrals like a PPO.
Primary Care Physician (PCP)
Your main doctor who provides routine care and coordinates specialist referrals in HMO plans.
Referral
Authorization from your primary care doctor to see a specialist, required by some insurance plans.
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