What Is an HMO Insurance Plan?

A health maintenance organization, or HMO, is a health plan that tends to have fewer expenses than other types of plans, but you may have fewer healthcare options.

A health maintenance organization, or HMO, is a health plan that tends to have fewer expenses.

Your only costs are monthly premiums — the monthly amount you pay for insurance — copayments, and coinsurance . Those costs are usually lower than other types of plans. Your deductible will probably be lower too — if you have one.

The flipside of less expensive care is that these managed health insurance plans also restrict your healthcare choices to in-network-care from doctors who work for, or contract with, the HMO.

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You usually need to choose a primary care doctor to oversee your care. To see a specialist, you need a referral from your doctor. That also goes for having your plan cover physical therapy or even buying medical equipment like a wheelchair or home oxygen system. If your healthcare provider leaves the HMO, your plan will tell you — and you’ll have to choose another doctor.

You can’t get care from just any doctor, hospital, or pharmacy. You’ll have to pay the full price for a prescription from an out-of-network pharmacy. Accidentally have an expensive test like an MRI at a non-participating imaging center, and you’ll be on the hook for the entire cost. HMOs rarely cover any out-of-network care, except for emergencies.

Your plan will have specialists in your network, but sometimes you may need to go outside of the network for the best care. If you do, the HMO will first have to approve a referral.

You may have to live or work in the HMO’s service area, usually covering only certain counties or zip codes. If you travel, spend a lot of time away from the HMO’s service area, or have a child attending college outside your zip code, an HMO may not be the best plan. Your child, for instance, will have to travel back to the service area for healthcare.

HMOs, based on the concept that you can prevent future medical problems if you maintain your health now, were popular in the 1990s. More people are choosing other less expensive insurance options, however, such as consumer-driven, high-deductible health plans or PPOs. Moreover, many preventive healthcare services are now covered according to federal law.

It is very important to understand all of your in-network, and out-of-network, costs before you sign up for a health insurance plan. You should always consider all of your anticipated healthcare costs, as well as plan for unanticipated healthcare costs, before choosing a health plan.

Carefully read your open enrollment health insurance marketplace, employer enrollment plan, or Medicare or Medicaid options before choosing the right plan for you and your family.

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