Health Maintenance Organizations


Benefits Summary Plan Description

Health Maintenance Organizations

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Health Maintenance Organizations (HMOs)

HMOs offer health care for participants and their families through a limited network of health care providers. For more information visit the sections below.

How the Plans work

HMOs require that participants receive all medical care exclusively from the HMO's network of providers in order for them to receive benefits. When a participant enrolls in an HMO, he or she, as well as his or her covered dependents, may need to select a primary care physician (PCP). This PCP would then provide all routine medical care and will refer the participant to a network specialist whenever he or she needs specialty care.

If a participant receives medical care without going through his or her PCP first, or if the participant's care is not authorized by the plan, the HMO may not pay any benefits, and the participant will pay the full cost of any out-of-network or unauthorized care. For most plans, emergency care received out-of-network or unauthorized by the plan will generally be covered.

In general, when the participant visits a provider, he or she pays the required copayment for covered services. No further payment is required. The participant does not have to file a claim form after receiving care.

HMOs generally include a prescription drug benefit.

For more information about how a specific HMO works and what payments are required, participants should refer to their evidence of coverage booklet.

Choosing a Primary Care Physician (PCP)

Generally, the participant and each of his or her covered dependents must select a primary care physician (PCP) from the HMO's network of providers. Each covered person may select his or her own PCP and each participant can generally change his or her PCP at any time during the year.

To select or change a primary care physician, participants should call the HMO's member services number on the back of their ID card.

ID Cards

When a participant enrolls in an HMO, he or she, and each of his or her covered dependents, will generally receive an ID card in the mail. Participants should be sure to keep their ID cards with them at all times.

A participant must present his or her ID card when he or she:

  • Visits a doctor's office;
  • Is admitted to a hospital; and
  • Fills a prescription at a retail pharmacy.

The participant's ID card contains important information about the participant and the HMO plan. By presenting the card to their health care provider, participants ensure that they receive the right level of coverage.

If a participant does not receive an ID card, he or she should contact the HMO's Member Services.

What is covered and what is not covered

Generally, HMOs cover preventive, wellness, emergency, surgical, and hospital services.

For a complete list of what is covered by an HMO, participants should refer to the HMO's Evidence of Coverage.