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What Is an HMO?

 

How an HMO Works

If you’re looking for a health plan that’s easy to understand, easy to use and easy on your wallet, an HMO may be just what you need for you and your family.

An HMO is designed to keep costs low and predictable. With one primary doctor to coordinate your care, an HMO health plan is easy to use and may be just what you need. HMO plans often offer:

  • Monthly premiums which are often lower than other types of plans.
  • Access to certain doctors and hospitals, called your HMO provider network, which helps control how much you pay for health care.
  • A primary care provider (PCP) who you see for routine check-ups, physicals, colds and flu. For most HMO plans, you must select a PCP.
  • Coordinated care. Some HMO plans require your PCP refers you to specialists and some HMO plans let you see specialists in your network without a PCP referral. Check your benefit details before you make an appointment with a specialist.

It's Personal

An HMO health plan is designed so that you have care personalized to you. Most of the time, your care is coordinated by one doctor who knows you — your health history, current issues and medication, lifestyle and how your family's health history may affect your health.

Getting Started

When you first sign up for an HMO health plan, you choose, or are assigned, a PCP. Each person on your plan can pick their own PCP. PCPs typically focus on general internal medicine or family medicine. Women and girls can choose an OB/GYN or a Woman's Principal Health Care Provider (WPHCP) as their PCP. Older adults can choose a geriatric doctor. Children can have a pediatrician as their PCP.

Know Your Network

To make sure a provider is in your plan's network, learn about our Find Care tool. This tool allows you to find the doctors, hospitals and other providers covered by your plan.

If you're a BCBSTX member, register or log in to  Blue Access for MembersSM, our secure member website, for a personalized search based on your health plan and network.

  • If you're a new patient, see your PCP right away. When you make your first appointment, let the doctor's office know that you're a new patient. Your PCP should be your first stop when you need care. Please call their office or after-hours phone number for any health care needs. In emergency cases, they may have you go to the hospital.
  • Before you go. You may need to get prior authorization (or pre-approval) from BCBSTX before getting certain tests or services. Your doctor's office will call the prior authorization number listed on your BCBSTX member ID card to confirm. You can also call before you go for care to confirm authorization.
  • Get a referral. If you need to visit a specialist, behavioral health care provider or hospital for non-emergency services, your PCP will refer you to one. Make sure the specialist or behavioral health care provider is in your network. Women don't need a referral to see your in-network Woman's Principal Health Care Provider.
  • For real emergencies. If your illness or injury is life-threatening, call 911 or go to the nearest emergency room. You don't have to stay in-network or get a referral. Just let your PCP know that you had an emergency as soon as you can so they can follow your treatment and manage any follow-up care needed. Not sure what’s an emergency? Learn more.

Changing Your PCP

You can change your PCP at any time unless you are hospitalized or in the second or third trimester of pregnancy. To find a different PCP, use our Find Care tool.

It's Affordable

HMO health plans are designed to control costs through preventive health care that helps you avoid serious and costly health problems. Your costs are also kept low because the doctors and hospitals in the HMO provider network agree to offer their services at a set price.

The HMO network may include care and services from:

  • Doctors
  • Hospitals
  • Clinics
  • Pharmacies
  • Labs
  • Imaging centers
  • Medical equipment centers

In most cases, your HMO health plan won't cover any of your expenses if you go to a provider who is not in your network.

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