What is an HMO?
A Health Maintenance Organization (HMO) provides complete medical services from a closed network of providers. Generally, coverage is not provided and benefits are not paid if you get care outside of the network without prior approval from your primary care physician (PCP) and your medical group. HMO plans use PCPs to manage your care. The HMO provides comprehensive services for a monthly premium through a group of providers, i.e. Medical Group, in a fixed geographic area.
How are HMO’s organized?
Your HMO(medical plan) and Medical Group have contractual agreements with doctors, labs, hospitals and other providers or facilities. The medical provider submits claims to your insurance through your medical group.
HMO_Organization_Chart.pdf
What is a primary care physician?
A primary care physician (PCP) is a doctor you choose to manage all your health care. Your PCP coordinates your medical care, providing preventive and routine care and referrals to specialists and hospitals when you need them. A PCP can be an internist, a family or general practitioner, or a pediatrician for a child.You choose your PCP/medical group from the network of doctors in your health plan.
What is a Medical Group?
A medical group is an association of medical providers who work closely together and negotiate with insurance companies as one legal entity.Your medical group is the group of doctors and other providers that your primary care doctor is in. The medical group has a contract with the HMO (insurance plan) to provide your care. Your medical group is pre-paid by your medical plan to provide care to you.
Do I need to select a PCP?
You must choose a PCP if you are enrolled in Health Net, Western Health Advantage (WHA) and Anthem Blue Cross PLUS. Participants enrolled in the Kaiser Permanente plan are not required to choose a PCP. The selected PCP must be within 30 miles of your work or home address.
If you do not select a PCP/Medical group, it will be assigned to you. Always check you medical plan ID to ensure you are assigned to your desired PCP/medical group.
Newborns are automatically assigned to the mother’s medical group for the first 30 days. After that time, the baby may be assigned to a different PCP/Medical group.
Can each member of my family go to a different PCP and/or belong to a different Medical Group?
Each family member may select a different PCP and/or Medical Group. You select your PCP/medical group when you enroll in your medical plan.
When can I change my PCP and how do I make that change?
In most cases, you can change your PCP/Medical group at any time during the year. To change your PCP/medical group, contact your medical plan Customer Service using the number on your medical ID card. If you call prior to the 15th of the month, the change will be effective the first of the following month.
How do I see a specialist?
Referrals are usually made to a specialist within your medical group. Your PCP will provide you with a referral form and obtain authorization if needed. No referral is needed for annual OB/GYN exams as long as the provider is part of your medical group.
Can I see a specialist outside my medical group?
If you are enrolled in Health Net, WHA or Kaiser you may not see a specialist outside of your medical group unless you have received authorization from the medical group to see an out-of-network provider. If you are enrolled in the Anthem Blue Cross PLUS plan, you may self-refer to a specialist outside your medical group network, but you will be subject to the higher-cost out-of-network benefits.
What happens if I get care outside my HMO network without my PCP’s referral?
If you get care outside your HMO network without your PCP and medical group’s referral/approval, your insurance will not pay for the cost of care unless it is considered an out-of-area medical emergency. All HMO plans cover emergency care for injury or illness worldwide. You must contact your health plan within 48 hours of getting emergency care. If you have questions about emergency care or getting care when you travel, contact your medical plan’s customer service line using the number on your medical ID card.
The MEDICAL PLAN COMPARISON CHART shows how an HMO compares to other types of medical plans.