What’s an HMO?

An HMO is one kind of managed care plan. HMO stands for health maintenance organization.

Topics on this page

• HMO basics
• Why would I choose an HMO?
• Why would I NOT choose an HMO?
• Medi-Cal and Medicare plans

HMO basics

Primary care doctor: In most HMOs you must have a main doctor, called a primary care physician, or PCP. This doctor gives you most of your care and refers you for other services when you need them. Usually, you must see this doctor first before you can see a specialist. Your primary care doctor must be in the HMO’s network.

Medical group: Your medical group is the group of doctors and other providers that your primary care doctor is in. The medical group has a contract with the HMO to provide your care.

Networks and medical groups: Each HMO has a network of doctors, medical groups, labs, hospitals, and other providers who work for the HMO or have a contract with it. You must get approval from your HMO to get care from a provider outside the network, unless it’s an emergency, or you need urgent care and are outside your plan’s area. Most of the providers you see are also in your medical group. Ask the plan to mail you a copy of its provider directory. Or look on the plan’s website.

Referrals and pre-approval: You must have a referral to see a specialist or get most other services. Your HMO or medical group must approve many of your services before you can get them. Usually it is your doctor who gives you a referral and asks for pre-approval.

Why would I choose an HMO?

• You want to save on costs. HMOs are usually the least costly health plans you can get (except for high deductible plans).
• HMOs are more highly regulated than PPOs and must cover basic benefits.
• You want to have a primary care doctor who can help you decide what other care you need and how to get it.
• You want to simplify your health care costs. Usually the only costs you pay in an HMO are set co-pays. You do not get a bill for a percent of the cost of the service. And you do not have to submit claims.

Why would I NOT choose an HMO?

• You want to be able to see specialists and other providers when you want to, without having to get a referral and pre-approval.
• You want the flexibility to see providers who are not in the network, even if you have to pay more.

Medi-Cal and Medicare plans

If you have Medicare, Medi-Cal, or Healthy Families, you may get your services through an HMO.

• Healthy Families plans are for children in families with low incomes.
• Medi-Cal Managed Care plans are for people with Medi-Cal.
• Many Medicare Advantage plans are for people with Medicare. There are also Medicare Advantage PPOs.

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