Is an HMO Plan Right For You?

Scripps Health.
2022-09-09T15:43:26-07:00

Learn how HMO health plans work, their benefits and whether this budget-friendly, preventive-focused option is right for you.

Budget-friendly HMOs offer low-cost, comprehensive care

Open enrollment is your chance to take a good look at your health insurance benefits. It is the one time each year when you can make changes to your health plan or even pick a new one.

Whether you’re planning ahead for your family’s needs or just trying to save money, choosing the right plan can benefit your health and your budget.

One popular choice is a Health Maintenance Organization, or HMO plan. These plans usually have low monthly costs and often no deductibles, which means your insurance starts helping with costs sooner, rather than later.

HMOs mainly focus on preventive care and wellness. A primary care physician (PCP) typically manages your care and refers you to specialists as needed.

“An HMO plan is a good fit for many people,” says Anil Keswani, MD, corporate senior vice president, and chief medical officer of ambulatory care and accountable care operations at Scripps. “HMOs are affordable and their focus on preventive care helps you get and stay healthy throughout all the stages of life.”

HMOs vs other health insurance plans

When comparing HMO insurance to other health plans, the main factors to consider are cost, flexibility and network size.

If you’re looking for affordable, preventive-focused care, an HMO plan might be right for you. However, keep in mind that HMOs require you to stay within the plan’s network of doctors and hospitals and usually require referrals to see specialists. This might not be the right plan for you if you travel often should a health issue occur outside of your network’s coverage.

If you want more flexibility to choose providers, a Preferred Provider Organization (PPO) plan may be a better option. PPOs allow you to see out-of-network providers, but they typically cost more. PPOs also do not require referrals to see specialists.
How do HMOs work?

Each HMO is made up of a network of doctors, walk-in clinics, hospitals, labs, imaging centers and other services so that you have the full spectrum of medical care available.

HMOs are able to keep costs down by limiting care to their own networks, encouraging preventive services and requiring referrals before you see specialists.

Here’s what you can expect from an HMO and how it guides your care:
1. You must stay in-network

HMO plans usually do not cover care from providers outside their network, except in emergencies. If you see an out-of-network provider for non-emergency care, you might have to pay the full cost.
2. You must choose a primary care physician

When you join an HMO, you’ll need to choose a primary care physician (PCP) from the plan’s approved list.

Your PCP can be a family medicine doctor, internist or pediatrician. Many HMOs let women choose a gynecologist as their primary care provider.

Your PCP is your main point of contact for most medical needs and coordinates your care across the system.

Your primary provider handles:

Annual physicals and screenings

Vaccinations and preventive care

Referrals to specialists

“Your PCP will be your main point of contact for all of your medical needs, including your lab tests, treatments, specialist appointments and other care,” Dr. Keswani says. “They get to know you over time and act as the quarterback for your care.”

Usually, preventive care with your primary care physician does not require co-payment. This includes wellness visits, vaccinations and preventive screenings, such as mammograms and skin cancer screenings.
3. Authorization is required for specialist care

To see a specialist, like a cardiologist, endocrinologist or orthopedist, you’ll need a referral from your primary provider. Your HMO plan must approve the service before it is covered.

Additionally, your HMO must authorize tests, treatments or procedures, such as MRI, physical therapy or surgery. Services must be provided within the network unless they are not available.

Exceptions are made for emergencies where immediate care is needed, even if it’s from an out-of-network provider.
Is an HMO right for you?

An HMO might be a good it if you:

Want to save money on monthly premiums and out-of-pocket costs like copays and prescriptions

Prefer a coordinated, team-based care model

Are comfortable using a specific network of doctors and hospitals

Like having one doctor manage your care

If you are thinking about enrolling in an HMO, also consider the following:

If you already have a doctor you like, make sure they are in the HMO network. Ask if you can change your primary care physician during the year if desired.

If you take prescription medications, find out if they are covered by your plan and if a generic version is required.

Ask how mental health, urgent care and telemedicine are covered

Understand how to get care if you are traveling and must go to an out-of-network provider.
Don’t miss open enrollment deadlines

Open enrollment is your chance to make sure your health plan still meets your needs. Use this time to explore your options. Take time to compare HMO vs PPO options and make an informed choice that works best for you and your family.

If you miss the deadline, you’ll remain in your current plan until the next open enrollment period — unless you experience a qualifying life event (like marriage, a new baby or job loss). This is known as a special enrollment period.

Key open enrollment periods:

Employer-sponsored insurance: Dates vary but typically start in the fall; check with your HR department

Medicare annual enrollment: October 15 to December 7

Covered California Open Enrollment: November 1 to January 31
Health insurance at Scripps

Scripps accepts most health insurance plans, including PPO and HMO plans. With locations across San Diego County, you’ll find convenient access to:

Primary care physicians, including pediatricians

Over 100 medical and surgical specialties

Walk-in and urgent care services

Four hospitals across five campuses

Virtual care options like telemedicine