What Is An HMO?

What is an HMO?

If you're looking for a health plan that's easy to understand, easy to use and easy on your wallet, an HMO may be just what you need for you and your family.

It's Care. Simplified.

An HMO, or Health Maintenance Organization, is designed to keep costs low and predictable. With one doctor to coordinate your care, an HMO health plan is easy to use and may be just what you’re looking for.

An HMO health plan offers:

  • Monthly premiums, copays and deductibles are often lower than other types of plans.
  • Access to certain doctors and hospitals, called your HMO provider network, which helps control how much you pay for health care.
  • A primary care physician (PCP) who you see for routine check-ups, physicals, colds and flu. Your PCP will refer you to a specialist for more serious illnesses.

HMO. It's Personal.

An HMO health plan is designed so that you have care personalized to you. Your care is coordinated by one doctor who knows you — your health history, current issues and medication, lifestyle and how your family's health history may affect your health.

Getting Started

When you first sign up for an HMO health plan, you choose, or are assigned, a primary care physician (PCP) who's part of a medical group/independent practice association (MG/IPA).

Each person on your plan can pick their own PCP. PCPs typically focus on general internal medicine or family medicine. Women and girls can choose an OB/GYN or a WPHCP as their PCP. Older adults can choose a geriatric doctor. Children can have a pediatrician as their PCP.

If you're a member, you can find your PCP or your medical group listed 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.

Working with Your PCP

Your PCP is your partner in keeping you healthy. Follow these guidelines to work with your PCP: Download the You and Your Doctor guide

  • If you're a new patient, see your PCP right away. When you make your first appointment, let the doctor's office know that you're a new patient. Going right away will help avoid delays later when you are sick or need a referral. Helpful hints for finding a new doctor.
  • Get a referral. If you need to see a specialist or behavioral health care provider, your PCP will refer you to one. Make sure the specialist or behavioral health care provider is in your network. Women don't need a referral to see your in-network Woman's Principal Health Care Provider (WPHCP). In addition, you will need a referral to visit a hospital for non-emergency services. You can search for participating hospitals and providers in Provider Finder to see who is covered in your network.
  • Call when you need care. Your PCP should be your first stop when you need care. If the office is closed, call the doctor's after-hours number. For a common illness and injury, like a cold, flu, minor cuts or burns, they will either fit you into their schedule or refer you to another doctor or clinic. In some cases, they may have you go to the hospital.
  • For real emergencies. If your illness or injury is life-threatening, call 911 or go to the nearest emergency room. You don't have to stay in-network or get a referral. Just let your PCP know that you had an emergency as soon as you can, so they can follow your treatment and manage any follow up care needed.

Can I Change my PCP?

Of course! You can 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: Search 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:
    • Online
      Log in to Blue Access for Members
      Choose the Change MG link
      Follow the instructions
    • Phone
      Call the Customer Service number listed on your BCBSIL member ID card.

HMO. It's Coordinated.

HMO health plans are designed to help you stay healthy. Having one health care expert coordinate all your health care needs keeps your costs and your health on track. An early diagnosis and treatment can keep many common health issues from getting worse.

Year after year, BCBSIL HMO health plans have proven to help improve member health results and lowered their overall cost of care because health issues are managed before they get serious. People with chronic conditions such as asthma and diabetes have seen the greatest results.

HMO. It's Affordable.

HMO health plans are designed to control costs through preventive health care that helps you avoid serious and costly health problems. Your costs are also kept low because the doctors and hospitals in the HMO provider network agree to offer their services at a set price.

The HMO network may include care and services from:

  • Doctors
  • Hospitals
  • Clinics
  • Pharmacies
  • Labs
  • Imaging centers
  • Medical equipment vendors

In most cases, your HMO health plan won't cover any of your expenses if you go to a provider who is not in your network. Here's why: Providers set their own prices for their services. These prices can vary by a few hundred to thousands of dollars for the same service. BCBSIL contracts with network providers to offer a service at a set price. Because out-of-network providers don't have a contract with us, we can't control how much they charge you. So to avoid getting big bills, make sure you stay in your network.

How do I know if a provider is in my network?

To make sure a provider is in your plan's network, search Provider Finder®, our online directory. Provider Finder also has a cost estimator to help you find costs for health visits, procedures, surgeries, diagnostics and imaging, vaccinations/immunizations and other services.

If you're a BCBSIL member, register or log in to Blue Access for MembersSM, your secure member website, for a personalized search based on your health plan and network.

Helpful hint: No matter which plan you have, before you need care, get to know your plan, what's covered and where you can go for care. Knowing how your plan works may save you time and money. Learn more about Making Insurance Work For You.

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Last Updated: Jan. 24, 2023