HMO stands for Health Maintenance Organization. It is a type of health plan meant to help you focus on controlling your health care costs while making sure you get quality care. With an HMO, your care is managed by a primary care physician (PCP) who can take care of many of your health care needs. In addition, HMOs usually offer broader coverage and have lower monthly premiums. Plus, out-of-pocket costs are more predictable than other types of plans.
When comparing PPO versus HMO, it's important to note that, unlike PPOs, HMOs only cover in-network health care services. This means that you may be responsible for the cost of your care if you visit a doctor or hospital outside of your network. In addition, some HMOs may have a smaller provider network and lower monthly premium than other HMOs.
How to Use Your HMO
- See your primary care physician (PCP) first. Unless there is an emergency, your PCP should be your first stop when receiving health care. For women, a PCP can be an obstetrician/gynecologist (OB/GYN).
- Get a referral. If you need to see a specialist, you must first get a referral from your PCP. This is another difference between HMO and PPO plans. When getting a referral, make sure the specialist is in your network. You do not need a referral from your PCP to see your in-network Woman's Principal Health Care Provider (WPHCP).
- Stay in network. Except in emergencies, HMO plans only cover the cost of care given by doctors and hospitals in your provider network. If you visit a doctor or a hospital that is not in your network, you may be responsible for the entire cost of your care. To avoid these costs, check Provider Finder® to ensure that you receive services in your plan's network.
- Know where to go.Whether you're experiencing an emergency or scheduling an annual exam, where you go for care matters. Before you see a doctor, make sure you know how your plan works, what's covered and where to go. It may save you time and money. Learn more.
About Your Primary Care Physician (PCP)
Another difference between HMO and PPO is the primary care physician (PCP). When you first sign up for an HMO, you choose or are assigned a PCP and a medical group/independent practice association (MG/IPA).
A PCP is a doctor or medical professional who treats and coordinates your health care needs. PCPs typically focus on general practice, internal medicine and family practice. Women and girls may choose an OB/GYN or a WPHCP for their PCP. A pediatrician can serve as your child's PCP. You and your family members do not need to select the same PCP.
If you are new to an HMO plan, get started by following these guidelines:
- Find your PCP or your medical group on the front of your Blue Cross and Blue Shield of Illinois (BCBSIL) member ID card or by logging in to Blue Access for MembersSM, our secure member website.
- If you're a new patient, see your PCP as soon as possible. When you make your first appointment, let the doctor's office know that you're a new patient. Going as soon as you can will help avoid delays later when you are sick or need a referral.
- Change your PCP or medical group/IPA at any time, except if you are hospitalized or in the 2nd or 3rd trimester of pregnancy.
- To change doctors within the same medical group: Use Provider Finder to find doctors in your medical group. Then, call the medical group (MG/IPA) on your BCBSIL ID card and ask to change doctors.
- To change to a different medical group:
- Log in to Blue Access for Members
- Click on the Doctors & Hospitals tab
- Choose the Change MG link
- Follow the instructions
Call the Customer Service number on the back of your BCBSIL member ID card.