What is an HMO?

What is an HMO?

• A. A type of plan that covers only emergency services
• B. A plan that relies on nationwide out-of-network coverage
• C. A hospital-first arrangement with no primary care
• D. Health Maintenance Organization; requires in-network care and PCP referrals

Answer: (D)

An HMO is a Health Maintenance Organization that requires you to use providers within a specific network and to go through a designated primary care physician to access most services. Your PCP acts as a gatekeeper, so you usually need a referral to see specialists. Because care is coordinated through the PCP and the network, costs are typically lower and preventive care is emphasized, but you have limited or no coverage for out-of-network services except in emergencies. This is why the description of in-network care with a PCP referral best captures what an HMO is. The other scenarios—coverage limited to emergencies, relying on nationwide out-of-network coverage, or a hospital-first arrangement with no primary care—don’t describe how an HMO operates.

An HMO is a Health Maintenance Organization that requires you to use providers within a specific network and to go through a designated primary care physician to access most services. Your PCP acts as a gatekeeper, so you usually need a referral to see specialists. Because care is coordinated through the PCP and the network, costs are typically lower and preventive care is emphasized, but you have limited or no coverage for out-of-network services except in emergencies. This is why the description of in-network care with a PCP referral best captures what an HMO is. The other scenarios—coverage limited to emergencies, relying on nationwide out-of-network coverage, or a hospital-first arrangement with no primary care—don’t describe how an HMO operates.