HMO stands for Health Maintenance Organization, a common type of health insurance. Many employers offer this type of plan because it offers a specific network of health care providers at a lower cost.

HMO Pros –

• Health insurance HMO premiums may be lower than those for other types of health insurance plans.

  This is because members are expected to use a set network of health care providers that are contracted to serve members at a lower rate. These networks can vary, but generally offer a wide range of care. For example, Unity’s network includes UW Hospital & Clinics, Wisconsin’s #1 Rated Hospital* as well as a full range of specialty care services.

• HMO health insurance plans tend to focus on wellness and prevention, offering perks for a healthy lifestyle that may include cash rewards for working out, eating healthy and more.

HMO Cons –

• HMOs generally require members to get prior approval before seeing a specialist. This can be a hassle for those who know they need a specialist and don’t want to waste time going to their PCP first. However, some HMOs, such as Unity, do not require members to get a referral from their PCP to see a specialist.
• Some HMO provider networks can be restrictive. It’s important to note that if HMO members use clinics or hospitals outside of their network, they may be liable for the entire cost of the care. In some cases, HMOs will pay for care outside of the network if the care has received prior approval.  It is important to get prior approval before going outside of the network for care.

Another note – out-of-network emergency care is covered by all plans (by law). However, care that is not classified as emergency care, such as in-patient care after emergency treatment, may not be covered. It is important that you call your health insurance HMO company as soon as you receive out-of-network emergency care so that you may receive any follow-up care in-network.

Want to learn more about health insurance HMOs? Check out our HMO resources, or get a quote for one of our HMO plans.