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Everything you need to know about this type of coverage.  

Health Maintenance Organization, or HMO, is a type of health insurance coverage that usually requires members to get care from doctors who work for or contract with the HMO. HMO health insurance generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

Learn about HMO health insurance plans in Wisconsin here.

How do HMO health insurance plans work?

Most HMOs require you to choose a Primary Care Physician (PCP) that coordinates your health care within the network. Many HMOs require you to get a referral from your PCP to see a specialist, but Quartz HMO members may see an in-network specialist without a referral. 

If you have an HMO health plan, you generally don’t have to file insurance claims because the health care provider usually handles that process for in-network claims.  However, you may receive a bill directly from the health care provider for any service not covered by insurance.  This may include copayments, coinsurance and charges for care that is not covered by insurance.

If you use an out-of-network provider, you may be billed directly by that provider for some or all of the health care service.

What do HMO health plans cost? 

The cost of HMO health insurance in Wisconsin is dependent on five factors – where you live in the state, how many people are insured, your age, whether you use tobacco, and what type of HMO plan you choose.

All ACA-compliant health plans provide a detailed Summary of Benefits and Coverage (SBCs) that describe what the plan covers and potential out-of-pocket costs. You may view these SBCs before you purchase your health plan. Once you have purchased a health plan and make a claim, insurers provide an Explanation of Benefits (EOB) document that explains what your coverage paid for your health care.

What are the alternatives to HMO plans?

In Wisconsin, other types of plans typically fall into three other categories: 

  • PPO, or Preferred Provider Organizations that cover care both inside and outside the plan’s provider network. Members generally pay more of the cost for out-of-network care
  • POS, or Point of Service plans are a cross between HMOs and PPOs. Members may need a referral for a specialist and the plan may also cover some of the costs for out-of-network care
  • EPOs, or Exclusive Provider Organizations, are very much like an HMO, but most don’t cover care outside of the plan’s provider network 

Now you know what HMO health insurance is, how it works and some alternative options.

If you're ready to start shopping for coverage, Quartz offers a variety of health plans in Wisconsin that include guaranteed access to UW Health and American Family Children’s Hospital. Check out our health insurance plans right now.