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.