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A Health Maintenance Organization, or HMO, is a very common type of health insurance plan in Wisconsin. If you’re considering an HMO plan, it’s important to know a few facts:

1. Your care will be coordinated by a Primary Care Physician (PCP).

Your PCP will be your go-to provider for care. They will work with you to determine what care you need and many times, what specialists you should see. Some HMO plans allow you to choose a PCP, while others assign a PCP to you. On the surface, this seems like a small difference, but it may be very important. For example, it’s possible that you could be assigned a PCP who has limited hours or is located in an inconvenient location. However, if you’re able to pick your own PCP (such as with any Quartz Health Insurance HMO plan), you can pick a PCP based on location, gender, languages spoken and a range of specialties.

Learn about HMO plans in Wisconsin.

2. Your HMO plan may require a referral from your PCP to see a specialist.  

Some HMO plans not only assign you a doctor (PCP) to coordinate your care, they also require your PCP to refer you for specialist visits. Requiring a referral when you know you need to see a specialist can be a hassle and waste time. For example, if you know you have an eye problem and you need to see an eye doctor, it doesn’t make sense to have to get a referral from your PCP to see the eye doctor. You may want to make sure the HMO plan you choose allows you to see specialists without a referral (such as Quartz’s HMO plans).

3. Stay within the HMO plan provider network.

HMOs have contracts with health care providers within a specific network. This means that these providers are able to serve members with greater efficiency, saving time and reducing processing fees and other costs. It’s important to stay within the HMO plan’s network when you are getting health care. If you’ve been seeing a specialist for years, and are considering joining a HMO plan, be sure to check whether that specialist is in the HMO network. If not, you may end up paying some or all of the cost of seeing that specialist. 

The exception to this is emergency care. If you have an emergency and an in-network provider is not available or convenient, you won’t be responsible for the costs of the emergency care. However, any follow-up care must be provided by an in-network provider for it to be covered.

4. HMO plans can be less expensive.

One reason for the creation of HMOs is to help control health care costs and these savings may be reflected in the cost of HMO plans to members. Depending on the plan, the savings may be in premium costs and / or out-of-pocket costs such as copays.

5. Prior Authorization may be needed.

Like all plans, HMO health plans require some services and prescriptions to have Prior Authorization (approval from the insurance company before you have the service or prescription). If you are considering an HMO plan, check out the plan’s Prior Authorization lists for health care services, durable medical equipment (DMEs) and prescriptions. Prior Authorization determines and authorizes payment:

  • For the specific type and extent of care, DME, supply or prescription that is medically necessary
  • For a specific number of visits or the period of time during which the care will be provided, or the medicine prescribed
  • To a specific provider rendering the service

Prior Authorization varies by specific plan, so be sure and check ahead of time.

If you have more questions about HMO plans, learn more about HMO health insurance here or give us a call at 800.362.3310. Our knowledgeable and helpful customer service representatives are happy to answer your questions.