What is Health Maintenance Organization (HMO)?
Insurance glossary entry on BeCovered.ai for the term "Health Maintenance Organization (HMO)": A health plan that usually requires a primary care gatekeeper and referrals for specialists. Scope: plain-language meaning for coverage discussions; confirm definitions on your policy forms.
A health plan that usually requires a primary care gatekeeper and referrals for specialists.
Understanding Health Maintenance Organization (HMO)
HMOs emphasize coordinated care inside a defined network. Out-of-network care is often uncovered except emergencies. Lower premiums than many PPOs trade off for less flexibility.
Examples
- Employee selects an HMO during open enrollment for predictable copays.
- Specialist visit denied without PCP referral when plan requires it.
- HMO without out-of-network benefits except stabilization after ER visit.
Common Questions About Health Maintenance Organization (HMO)
Do HMOs cover telehealth?
Often yes for in-network telehealth vendors listed by the plan. Confirm coding and cost-sharing before the visit.
Can I switch PCP mid-year?
Usually yes through member services; some plans limit changes per quarter. Referrals in flight may need reissuance.
Related Insurance Types
Related Terms
Copay (Copayment)
A fixed amount you pay for a healthcare service at the time of the visit.
Coinsurance
The percentage of costs you share with your insurance company after meeting your deductible.
Deductible
The amount you pay out of pocket before your insurance coverage kicks in.
Out-of-Pocket Maximum
The most you'll pay for covered healthcare services in a plan year, after which insurance pays 100%.