Health Maintenance Organization (HMO) Plans

In HMO Plans, you typically must get your care and services from doctors, other health care providers, and hospitals in the plan’s network, excluding:

• Emergency care
• Out-of-area urgent care
• Temporary out-of-area dialysis

HMO Point-of-Service (HMO-POS) plans are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance. You must follow the plan’s restrictions, like getting prior authorization for certain benefits when required. Find and compare HMO Plans in your area at Songer Benefits.

Are prescription drugs covered in Health Maintenance Organization (HMO) Plans?

In most cases, prescription drugs are covered in HMO Health Plans. Ask about the plan. If you want Medicare drug coverage (Part D)

Do I need to choose a primary care doctor in Health Maintenance Organization (HMO) Plans? You must enter an HMO Plan that offers prescription drug coverage. If you enter an HMO plan without drug coverage, you can’t enter a different Medicare drug plan.

In most circumstances, you must select a primary care doctor in HMO Plans.

Do I have to get a referral to see a specialist in Health Maintenance Organization (HMO) Plans?

In most cases, you must get a referral to see a specialist in HMO Plans. Certain benefits, like yearly screening mammograms, don’t need 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 total cost.
• You must follow the plan’s rules, like getting prior approval for a particular service when needed.