What Is HMO Insurance?

What is HMO insurance? Read on to find out everything that you need to know.

Health insurance is something highly important for you and your family to have especially if you have a  lot of underlying medical conditions. There are multiple options for you to choose from when you buy your health insurance from the Marketplace. If you do have to buy your health insurance, make sure that you do proper research before selecting an option that works best for you.

Health plans are usually categorized on the basis of the extent of coverage they provide. These plans are categorized as bronze, silver, gold and platinum. Therefore, on the off chance that you are actually purchasing from your state’s Marketplace or from an insurance broker, you will have to select a health plan from either one of these categories. Remember that platinum plans offer the maximum amount of coverage whereas bronze plans provide you with the least amount of coverage. Furthermore, in case you are an individual who is less than 30 years old, you may also be able to purchase a high-deductible, catastrophic plan.

In addition to this, most of the insurance companies may offer one or more of these pretty  common types of plans: Health maintenance organizations (HMOs), Preferred provider organizations (PPOs), Exclusive provider organizations (EPOs), Point-of-service (POS) plans, and High-deductible health plans (HDHPs). High-deductible health plans (HDHPs) may be related to health savings accounts (HSAs). You must do proper research before choosing an option for yourself. If you are aware of the different types of health plans, it becomes all the more easy to choose one that meets all your health care needs and that too in a budget.

Are you thinking about what an HMO insurance plan is and how does it work? Let us have a look. HMO is an acronym for Health Maintenance Organization. It is a type of plan that permits you to visit a select network of doctors and specialists who work with your health insurance provider. These types of plans are particularly excellent for families who are on the lookout for a budget friendly way to maintain their health care expenses.

If you want to know more about what is HMO insurance, then you have come to the right place. We have gathered all relevant information to help you understand everything that you need to know. So, what are you waiting for? Without much further ado, let us jump right in!

What is HMO insurance and what does it mean?

A Health Maintenance Organization, or HMO for short, is an organization of medical care suppliers who consent to offer various types of assistances at lower costs negotiated by an insurance agency. Individuals pick a single doctor from a rundown of endorsed medical care suppliers. HMO individuals can just see a medical services expert like an obstetrician, rheumatologist, or cardiologist in the event that they get a reference from their Primary Care Physician (PCP), who is otherwise also called the gatekeeper.

HMO stands for “Health Maintenance Organization.” HMO plans offer a wide scope of medical care administrations through an organization of suppliers who consent to supply services to individuals. With an HMO insurance you will probably have coverage for a more extensive range of preventive medical care administrations than you would through another type of plan. In HMO Plans, you by and large should get your care and services from suppliers in the plan’s network, with the exception of:

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

In certain plans, you might have the option to get specific services through out-of-network means. However, it typically costs less on the off chance that you get your consideration from an organization supplier. This is known as  a HMO with a point-of-service (POS) choice.

A person who needs to get medical coverage may discover an assortment of health care coverage suppliers with one of a kind highlights. A health maintenance organization (HMO) is one sort of insurance supplier that is famous in the health care coverage commercial center. Furthermore, it is a coverage structure that gives inclusion through an organization of doctors. On the off chance that you see a doctor out-of-network, you may need to pay for the complete bill yourself. Crisis administrations at an out-of-network medical clinic should be canvassed at in-network rates, yet non-participating doctors who check you in the hospital can charge you.

In addition to this, Health Maintenance Organizations (HMOs) give health care coverage on the basis of a month to month or yearly expense. An HMO limits participant inclusion to clinical consideration given through an organization of specialists and other medical services suppliers who are bound by a contract with the HMO. These contracts both take into consideration for the expenses to be lower than that for conventional medical coverage. This is because the medical care providers have the benefit of having patients directed to them. However, in addition to this, they likewise add extra limitations to members of the HMO.

It can often be a difficult decision to make as to whether you should pick an HMO or not. Therefore, when concluding whether to choose an HMO protection plan, you should think about the expense of charges, cash based expenses, any prerequisites you may have for particular clinical consideration, and whether it’s critical to you to have your own primary care provider. By and large it will not cover out-of-network care except for in an extremely critical situation. An HMO may expect you to live or work in its administration zone to be qualified for inclusion. In addition to this, HMOs regularly give integrated care and their focus mainly revolves around the prevention of diseases and the overall health and well being of the patient.

Furthermore, there are many services/benefits given by an HMO. These services can vary contingent upon the organization and the wellbeing plan. It might cover health screenings, cancer screening, recommended medications, laboratory tests, X-rays, and different scans. HMOs for the most part cover pre-birth care as well as well-baby care. There are no case structures to round out. Here is the thing that you need to pay for a HMO:

  • Premium: This is the monthly amount you pay for insurance.
  • Deductible: Your plan may require you to pay the amount before it covers care except for preventive care.
  • Copays and/or co-insurance for each type of care: A copay is a flat fee, such as $15, that you pay when you get care. Coinsurance is when you pay a percent of the amount for care, for example 20%. These charges differ on the basis of your plan and they are added toward your deductible.

How does an HMO work?

A Health Maintenance Organization or HMO for short is a systematic and well structured public or private entity that gives fundamental and supplemental wellbeing administrations to its members. The association gets its networks of healthcare providers by signing contracts with clinical offices, primary care physicians and trained professionals. The clinical elements that go into contracts with the HMO are paid an expense that is already settled on to offer a scope of services to the HMO’s members. The concurred installment permits a HMO to offer lower charges than different kinds of medical coverage plans while holding a high caliber of care from its organization.

As an individual from a HMO, you’ll be needed to pick a primary care physician (PCP). Your PCP will deal with a large portion of your medical services needs. Before you can see a trained professional, you’ll need to acquire a reference from your PCP.

In spite of the fact that there are numerous varieties, HMO designs commonly empower individuals to have lower cash based medical services costs. You may not be needed to pay a deductible before inclusion begins and your co-installments will probably be negligible. You likewise ordinarily will not need to present any of your own cases to the insurance agency. Nonetheless, remember that you’ll probably have no inclusion for administrations delivered by out-of-network suppliers or for administrations delivered without a legitimate reference from your PCP.

HMO vs PPO: which is better?

At the point when you’re looking for medical coverage, you have a great deal of choices to browse through. Knowing the differences between various plans can assist you with picking the one that is ideal for your medical care needs and your budget. As you take a look at plans, you may see that a few plans are HMOs and some are PPOs. However have you ever wondered as to what their significance is and which one is better?

  • HMO stands for Health Maintenance Organization
  • PPO stands for Preferred Provider Organization

Every one of these plans utilize an organization of doctors, emergency clinics and other medical care experts to give you the greatest care. The difference between them lies in the manner in which you connect with those organizations.

With an HMO plan, you pick one primary care physician. All your medical care administrations and services first go through the doctor. This implies that you need a reference from your PCP before you can perceive some other medical care proficient, except for in a crisis situation. Visits to medical care experts outside of your organization commonly aren’t covered by your insurance.

For instance, in the event that you get a skin rash, you wouldn’t go directly to a dermatologist. You would initially go to your primary care physician, who’d inspect you. In the event that your primary care physician can’t be of any help, the individual in question will give you a reference to a confided in dermatologist within your network who might be able to help. One exemption for this is that women do not have to bother with a reference to see an obstetrician/gynecologist, or OB/GYN, in their network for routine administrations, for example, Pap tests, yearly well-woman visits and obstetrical consideration. Planning all your medical services through your primary care physician implies less administrative work and lower medical services costs for everybody.

PPO plans give you flexibility and are easy to adapt to. You needn’t bother with a primary care physician. You can go to any medical services proficient you need without a reference — within or out of your organization. Remaining within your network implies more modest copays and full inclusion. On the off chance that you decide to go out-of-network, you’ll have higher cash based expenses, and not all administrations might be covered.

Differences between HMO and PPO

Provider networks

A network is a group of medical care suppliers that are under agreement and bound by a contract with insurance agencies to offer limited administrations for a specific HMO or PPO plan. They commonly incorporate general doctors, alongside experts like dermatologists and bone and joint specialists. To get inclusion in an HMO, you should initially see your PCP, regardless of what the issue is. On the off chance that they can’t treat you, they will refer you to another person within the network. Remaining within your network in an HMO plan, you can anticipate the greatest protection inclusion. Go outside of the network and your inclusion evaporates. With a PPO, you can visit specialists outside the network and still get some inclusion, yet not as much you would in the event that you stayed in the network.

Claims forms

With an HMO, patients don’t have to record a case since medical care suppliers are paid straightforwardly by the insurance agency. Under PPO, in any case, patients should at times first pay out-of-network suppliers and afterward record a case for repayment from the insurance agency.

Cost analysis

When talking about the difference in cost analysis between PPO and HMO, you must know that with the former, the trade-off for getting the freedom of choice and flexibility is higher premium costs for the plan. Whereas the latter (an HMO) does not provide any coverage outside the network. However patients enjoy lower premium costs with an HMO.

Services covered

The scope of services given under the two plans rely upon the organization and the sort of plan taken, yet they are normally comparable.


Patients with a HMO plan needn’t bother with a reference during a crisis or for in-network visits to a gynecologist or obstetrician.


Much like the inclusion under an HMO is restricted to a network, the drug store areas where one can get their medicines refilled and covered under the arrangement are restricted also. PPOs permit patients to fill a remedy anyplace yet with extra charges for an out-of-network drug store.

Which one is right for you?

In the event that you like to have your healthcare facilitated through a single specialist, an HMO plan may be appropriate for you. Furthermore, on the off chance that you need more prominent flexibility or in the event that you see a ton of subject matter experts, a PPO plan may be the thing you’re searching for.

There is no widespread response to the subject of whether an HMO or a PPO is better. It is to a great extent dependent on the individual inclinations of clients. Basically HMOs give reasonableness, while PPOs give more prominent flexibility and opportunity of decision. Measurements show that a greater number of individuals are taken on PPO plans than HMO plans. In 2014, 58% of laborers picked a PPO as their boss provided a health care coverage plan, contrasted with only 13% of laborers who picked a HMO. Notwithstanding the prevalence of PPOs, an examination directed by the National Committee for Quality Assurance (NCQA) shows that HMO plans draw better consumer loyalty evaluations. The decision among HMOs and PPOs is essentially a decision among cost and comfort.

Features of an HMO insurance plan

To comprehend whether this sort of plan will work for you, it’s critical to additionally characterize HMOs by their key elements and highlighting points. As indicated by Inc. Magazine, “HMOs give a wide scope of extensive medical care administrations to their individuals in return for a fixed intermittent installment. Much of the time, members should choose a primary care physician from a rundown of endorsed suppliers, which typically incorporates internists, pediatricians, and general practitioners. These specialists go about as watchmen to organize all the essential medical services required for their patients.”

By and large with HMO designs, it’s imperative to remain within your supplier’s network of specialists to keep your cash based costs low. The primary care physician of your choice can allude to experts who are inside your HMO’s organization to guarantee you stay covered under your arrangement. As per CMS, “HMOs as a rule limit inclusion to mind from suppliers who work for or contract with the HMO. A HMO by and large will not cover or has restricted inclusion for out-of-network care besides in a crisis. On the off chance that you utilize a specialist or office that isn’t in the HMO’s organization, you may need to pay the full expense of the administrations you get.”

Cost of an HMO insurance plan

Regardless of the fact that HMO plans can be a little limiting and restrictive when it comes to deciding who your healthcare provider will be, they are often the more budget friendly types of insurance plans available. Furthermore, according to ValuePenguin, the average HMO plan can have a monthly premium of $230 — averaging to about $2,764 on a yearly basis.This is not exactly the normal month to month rate for different sorts of wellbeing plans, including POS, PPO, and EPO. At the point when you do get care from an in-network supplier, you might be answerable for a copay—or the sum you pay for your primary care physician visits—each time you get care. This customary sum can help you better deal with your cash based expenses instead of paying towards a yearly deductible or coinsurance.

What are the benefits of a HMO?

Numerous individuals appreciate having an HMO as health care coverage on the grounds that the arrangement doesn’t need claim forms to see a specialist or during hospital stays. A member of the HMO just needs to introduce a card that states evidence of protection at the doctor’s office or hospital. In an HMO the individuals may need to stand by longer for an appointment as compared to an indemnity insurance plan. The HMO charges a fixed month to month expense so its individuals can get medical care. There will be a little co-installment for each specialist visit; anyway with the HMO, charges can be determined unlike a fee-for-service protection plan. In spite of the fact that opportunity of decision is surrendered, cash based costs are low.

There are also a few disadvantages to having an HMO. The premium that is paid is barely enough to take care of the expenses of doctors and specialists in the network. The individuals are bound to a primary care physician and whenever managed care plans are altered, at that point the member will be unable to proceed with a similar PCP. A significant disadvantage is that it is hard to get any particular consideration in light of the fact that the individuals should get a referral from their PCP first. Any sort of care that isn’t a reference or a crisis isn’t covered. In terms of expenses, the HMO plan is one of the quickest developing sorts of managed care, while being the most prohibitive kind of medical services.

Employers and representatives select HMOs over PPOs because of lower expenses and high consideration coordination. Given below is a list of some of the top benefits of having an HMO insurance:

Focus on care coordination

One of the primary advantages of a HMO is the significant degree of coordination between suppliers, which improves on consideration for individuals and holds the expenses down. With an HMO, individuals select a primary care physician (PCP) who gives most essential care and facilitated care individuals may require from different suppliers. This incorporates references to speciality care, X-ray, research facility and different administrations. Individuals may see an out-of-network supplier just if their PCP or clinical group alludes them for care, for example, when there is certifiably not taking an interest supplier who can treat a particular condition. HMOs likewise will in general focus on health and sickness avoidance, and many will cooperate with employers to make programs explicitly customized for their representatives.

Lower overall costs

Most HMOs pay suppliers by capitation to help control medical services costs. Under a capitated installment plan, HMOs consent to pay suppliers a fixed sum for each part/each month. This places the suppliers at monetary risk for member care and supports care coordination among participating suppliers. Thus, it permits HMOs to value designs all the more seriously, which is the reason why HMO expenses are generally lower than PPO charges. Today, there are an assortment of HMO plans to browse through, including copayment plans, coinsurance plans and deductible plans. As of late, we’ve seen high-deductible wellbeing plans together with health savings accounts acquire notoriety because of lower month to month expenses and the potential tax savings.

Narrow networks

Numerous individuals avoid choosing an HMO since they don’t care for narrow networks. It’s critical to remember that “narrow networks” doesn’t mean limited entrance. Indeed, in California the Department of Managed Health Care (DMHC) expects HMOs to guarantee individuals get opportune admittance to mind. This implies the state places limits on how long individuals should stand by prior to seeing PCPs, trained professionals or other medical services suppliers.

Member perks

Notwithstanding exceptionally planned care and total lower costs, numerous HMOs offer extra types of assistance to individuals. This may incorporate admittance to a 24/7 nurse exhortation line, a call center for the benefits of all members, online entries to see or oversee benefits or speak with suppliers, wellbeing projects and sickness the executives programs. A significant degree of client assistance, including new part invite calls, are highlights individuals may discover with HMOs. The present managers and representatives need a wellbeing plan that is both moderate and simple to utilize. As you examine your decisions this open enlistment season, look again at all your choices. Notwithstanding expenses and cash based expenses, cautiously consider the supplier organization, care coordination and member advantages — you may find a HMO is appropriate for you.


Now that you have read this article, you know all about what is HMO insurance. HMO supporters pay a month to month or yearly expense to get to clinical benefits in the association’s network of suppliers, yet they are restricted to getting their consideration and administrations from specialists inside the HMO organization. Be that as it may, some out-of-network administrations, including crisis care and dialysis, can be covered under the HMO.

Charles Bains

Charles Bains

Charles Bains started his insurance career as a marketing intern before pounding the pavement as a commercial lines agent in Orlando, FL. As an industry journalist, his articles have appeared in a variety of trade publications. His insurance television career, short-lived but glorious, once saw him serve as the expert adviser on an insurance-themed infomercial (yes, you read that correctly). Having recently worked for various organizations, coupled with his broader insurance knowledge, Charles is able to understand our client’s needs and guide them accordingly. He is a gem for Insurance Noon as his wide area of expertise and experience have been beneficial in conducting further researches to come up with solutions and writing them in a manner which is easy for everyone including beginners to comprehend.

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