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What is HMO Medical Insurance?

Mary McMahon
Updated May 17, 2024
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HMO medical insurance is a health insurance product which is offered and managed by a health maintenance organization (HMO), a type of managed care provider. This type of insurance is widely used, and is especially popular for group insurance plans such as insurance which covers the employees of a particular company, or members of a particular organization. There are advantages and disadvantages to HMO medical insurance which can be weighed when deciding which type of insurance product to buy.

Under an HMO, members of the HMO have access to a network of care providers. In some cases, these people work directly for the HMO, while in other instances, they have contracts with the HMO. The health maintenance organization decides which kind of treatments it will cover and in what setting, and uses this to manage costs. Historically, such organizations have promoted preventative care, with the goal of preventing expensive medical conditions by keeping members as healthy as possible.

With HMO medical insurance, people pay a set fee every month to access providers in the network. Many HMOs require members to pick a primary care provider who acts as a first point of contact for patients. Patients must use this care provider to get referrals to specialists, and the HMO may refuse to pay for visits to specialists if the patient does not have referrals, or if the organization deems that a patient does not require specialist treatment. Other HMOs are more lax, and will allow patients to seek out specialists directly.

In exchange for a monthly fee, HMO medical insurance pays part of the cost of visits to network providers, and covers part of prescription costs as well. The rest is up to the patient, in the form of a copay. Copay schedules are published as part of patient contracts so that patients know how much to expect when they receive services or medications. Patients should be aware that these schedules can vary, depending on the service, and that an HMO medical insurance plan can opt not to cover certain things, even if they are things which the plan would normally cover, if the patient has not followed the proper protocol.

Such plans can be very limiting. For people who live in an area with a large number of HMO-approved care providers, accessing care can be relatively easy, but people in remote areas may need to travel for some types of treatment. People with complex medical needs may find HMO health insurance frustrating, as they may not be able to access certain treatments and their own preferred care providers under the plan.

WiseGEEK is dedicated to providing accurate and trustworthy information. We carefully select reputable sources and employ a rigorous fact-checking process to maintain the highest standards. To learn more about our commitment to accuracy, read our editorial process.
Mary McMahon
By Mary McMahon

Ever since she began contributing to the site several years ago, Mary has embraced the exciting challenge of being a WiseGEEK researcher and writer. Mary has a liberal arts degree from Goddard College and spends her free time reading, cooking, and exploring the great outdoors.

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Mary McMahon

Mary McMahon

Ever since she began contributing to the site several years ago, Mary has embraced the exciting challenge of being a...

Read more
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