HMO Health Insurance Review: A Complete Guide

Updated: November 9, 2022
hmo health insurance

Health Maintenance Organization (HMO) is a term you’ve likely come across if you’ve been looking into different healthcare options. HMO health insurance is the most prevalent type of insurance offered through the Affordable Care Act (ACA) and Medicare Advantage.

Many people prefer HMO plans since their monthly payments are generally less expensive than other types of health insurance. HMO health insurance plans offer some benefits but also have some restrictions.

What is HMO Insurance?

HMOs are a form of health insurance that often only pays for care from doctors and hospitals that are part of the HMO’s network. Unless essential, out-of-network services are not covered. You must reside or work in an HMO’s service area to be covered. HMOs are notable for their emphasis on wellness, preventative care, and integrated care.

All HMOs and other health plans in California fall under the Department of Managed Health Care (DMHC) jurisdiction.

  • Health maintenance organisations (HMOs) contract with a network of healthcare providers on the policyholder’s behalf. You must receive all of your medical care from the listed providers. This listing is known as a network.
  • Primary care physicians typically belong to a medical practice that agrees with the HMO. Your primary care physician handles most of your health needs. Your primary care physician will submit an authorization request to your health insurance company before referring you to a specialist, ordering diagnostic testing, or admitting you to the hospital.
  • A copay is an out-of-pocket expense you’ll be responsible for paying for each service.
  • Another possibility is a yearly deduction. Your HMO will not cover any costs unless you pay this yearly deductible.
  • HMOs, provide service areas. To join the HMO, you need to be a resident or employer in one of the eligible areas.

Some chiropractic, behavioral/mental health, and dental/vision care plans are also under DMHC’s watchful eye. These plans are known as “specialty” insurance because they are designed to pay for a narrow range of medical services. HMOs frequently use plans like these to provide their members with the specialized treatment they need.

How Does an HMO Function?

To make an informed decision about your health insurance during open enrollment (the time of year when you can choose or switch health plans) and to avoid any unpleasant surprises once you’ve signed up for an HMO, it’s important to familiarise yourself with how these plans work.

Make sure you do everything required to enroll in the HMO and start receiving coverage.

You Must Have a Primary Care Physician

  • Your primary care doctor manages your care in an HMO.
  • In an HMO, your primary care provider is crucial. If not, switch.
  • Your primary care provider must be in the HMO’s network. Your insurer will choose one if you don’t.

Specialized Treatments Require Referrals.

In most HMOs, your primary care provider decides if you need special care and refers you. Referrals are local.

An HMO referral is needed for the following:

  • To consult an expert.
  • To undergo physiotherapy
  • Get medical equipment like a wheelchair.

Referrals verify the medical necessity of treatments, testing, and specialized care. Without a reference, HMO won’t cover these services.

In this way, unnecessary support is cut out of the equation. It’s expensive because you have to see many doctors (a primary care doctor first, then a specialist) and get a separate copay for each one.

Copays are predetermined amounts paid for specific services. You may spend $30 to see your primary care doctor.

You Must Use Providers Within the Network

Every HMO has a network of providers. Doctors, pharmacies, specialists, hospitals, X-ray facilities, labs, and speech therapists are included.

Out-of-network care might be expensive for HMO members. Fill a prescription at an out-of-network drugstore or have blood tests at the wrong facility, and you might owe hundreds or thousands.

You must know your HMO’s network providers. You can’t assume a lab is in-network because it’s near your doctor’s office. Verify.

Sometimes out-of-network providers, such as a surgeon’s assistant or anesthesiologist, treat you without your knowledge.

When planning medical treatment, be sure everyone involved is in your HMO’s network.


Exceptions exist to the in-network requirement. Such as:

  • You have a medical emergency, like a life-threatening accident.
  • The HMO doesn’t cover your service. Rarely. If you need out-of-network care, contact your HMO in advance.
  • Your specialist isn’t part of the HMO when you join an HMO while undergoing complex specialty therapy. Case-by-case, most HMOs decide if you can finish therapy with your present provider.
  • You require emergency treatment or dialysis outside the network region.

HMO as an example

For instance, if you’re having severe headaches, you should make an appointment with your primary care physician first. Your primary care doctor may recommend you to a neurologist in your health insurance network. Without a reference, your insurance company is unlikely to cover a visit to a neurologist.

HMO Plan Types

An HMO’s main goal is to keep its members healthy. Your HMO would rather spend a little now to prevent disease than treat it later.

Your HMO will manage chronic conditions to keep you healthy.

Staff, group, open-panel, and network models are HMOs. Some HMOs have various divisions with distinct models, and employees can select.

  1. Staff Model

According to this HMO model, all medical staff is employed by the HMO and provide their services from HMO-owned facilities. Doctors see only HMO members.

  1. Group Model

Aside from being employed by the HMO, physicians and nurses also do not play a direct role in providing care. They are part of medical groups that feature doctors from various disciplines. The HMO makes one large payment to the group, and the doctors share the proceeds. Doctors only see HMO members, similar to the staff model.

  1. Open-Panel Model

The HMO hires the IPA on a contract basis. Unlike multi-specialty group practices, members of independent practice associations are not restricted from seeing patients not covered by health maintenance organizations. Primary care physicians can refer their patients to specialists or hospitals outside of the network for care. The HMO might not offer as much protection as the employee would have if they stayed within the network.

  1. Network Model

In this way, group and open-panel models are brought together. Health maintenance organizations (HMOs) typically have contracts with specialty-spanning groups, IPAs, and solo practitioners to deliver care to their members. HMOs of more recent vintage tend to choose this method.

HMO Health Insurance:  Pros & Cons

HMO insurance covers medical treatments within a network for a monthly cost. You can choose a primary care doctor and visit local hospitals. When shopping for health insurance, examine the advantages and pitfalls of an HMO.


  • Policyholders benefit when an HMO contracts with a network. Healthcare bills are the biggest. Unchecked, healthcare providers might overcharge for treatments and services. An HMO informs network providers what to charge. This saves money.
  • You can choose from many HMO networks. Choose an HMO that contracts with your preferred doctors and hospitals.


  • You’re limited to a specific network. You may have to pay for everything if you go out of network. You must choose your doctor carefully. Exception: a medical emergency. Moreover, you must be careful since the HMO may not agree with your definition of an emergency.
  • Most HMOs need a co-payment per visit. If you have a lingering ailment, you may need many co-payments. Costs can mount quickly.
  • HMOs make specialist coverage difficult. If you need expert care, you’ll need a referral. Your HMO won’t cover the visit. Also, make sure your specialist is on your network. Your condition may make this difficult. You’ll pay the full cost if you acquire an out-of-network referral and get treatment.

Differences Between HMO and Other Health Insurance Networks

The key differences between HMO health insurance plans and others are:

  • Costs (HMO is the cheaper plan of all)
  • Where care is available (HMOs being more restrictive than other plans)
  • Whether or not you need a PCP

Here are some alternative provider network plans.

Preferred provider organization (PPO): Care can be received from either in-network or out-of-network doctors under this type of health insurance. See specialists without a referral. These more flexible plans are more expensive.

Point of service (POS): A health insurance plan that enables in-network and out-of-network care. However, it is more expensive. POS policyholders must select an in-network PCP for routine visits, like HMOs. PCPs must authorize specialist referrals like HMOs.

Exclusive provider organization (EPO): EPOs, like HMOs, only cover in-network care in emergencies. Unlike HMOs, you don’t need a PCP or referral to see an in-network expert.


A PPO makes it easy to see a specialist (PPO). Also, referrals are not needed. With a PPO, you can receive care outside the network at a premium cost. HMO plans don’t allow out-of-network care unless in emergencies.

Moreover, PPO beneficiaries may prefer the plans’ flexibility, despite their higher cost. Choosing a PPO gives you more alternatives and freedom.


POS plans are hybrids with HMO and PPO components. POS insurance plans, like PPOs, enable in-network and out-of-network care, but the cost is higher.

Like HMOs, beneficiaries must choose an in-network PCP to manage treatment and approve specialist referrals. Some HMOs and many POS plans don’t require deductibles.


EPOs, like HMOs, are limited health insurance policies that only cover network services except in emergencies. Unlike HMO and POS plans, beneficiaries don’t need to choose a PCP. EPOs don’t require prior authorization to see in-network specialists.

What Companies Have HMO Plans?

Several insurance companies provide HMO options. HMO plans for individuals are available from various sources, including private insurance companies, the Health Insurance Marketplace established by the Affordable Care Act, and employer-sponsored insurance programs. Among the many insurance providers that provide HMO plans, some of the more notable are:

  • Blue Cross Blue Shield
  • UnitedHealthcare
  • Aetna
  • Humana
  • Cigna

Do your research before choosing an HMO plan. There is a wide range of HMO plans and insurance providers, with some being more flexible than others. High deductible health maintenance organization plans (HMOs) are available from some service providers and include even lower monthly premiums than traditional HMO plans but also feature higher out-of-pocket costs for medical care.

Health Insurance Companies: HMO Health Insurance Review

1. Blue Cross Blue Shield – HMO Insurance Review

Blue Cross Blue Shield has subsidiaries in most states. In states with BCBS, the insurance businesses are locally and independently owned.

Top HMO Health Insurance Features

BCBS is among the top HMO firms and insurance plans for several reasons.

Blue Distinction

BCBS, a prominent HMO provider, provides a Blue Distinction program that recognizes safe and effective care. Facilities and doctors must achieve stringent standards to participate.

Blue Distinction Total Care and Specialty Care are primary care programs.


Policyholders can predict healthcare costs with HMO insurance or a BCBS HMO plan. Most policies have a steady copayment, no deductible, and no paperwork.

BCBS HMO health insurance plans often feature Away From Home Guest Membership coverage for members who live outside their service area for 90 days.

Specialists without referrals
  • In several areas, BCBS HMO insurance doesn’t require referrals to see specific specialists.
  • Network OB/GYN, dermatologist, ophthalmologist, and optometrist.

Aetna Health Insurance Review

Aetna was founded in Connecticut in 1853. In 1951, Aetna began offering major medical insurance.

In the 1990s, Aetna merged with U.S. Healthcare to form Aetna U.S. Healthcare, the largest health benefits provider in the country.

Aetna serves over 39 million customers. Aetna policyholders in the United States can access the services of one million CVS Health clinicians.

Aetna sells health insurance on the exchange.

HMO: Patients with an HMO plan are usually covered only by network providers. Most specialists require a recommendation.

Aetna extra benefits

Aetna CVS Health plan holders enjoy CVS pharmacy incentives. Policyholders can get low-cost or free care at CVS’s 1,100 MinuteClinics. Policyholders get 20% off CVS brand health products.

Aetna’s Best Health Plans
  • NCQA evaluates the treatment quality, member satisfaction, and improvement efforts of health insurance plans.
  • NCQA awards five stars to health insurance plans. Aetna has some well-rated plans, but none are five-star. These Aetna plans got four stars.
Aetna complaints
  • Aetna’s complaint rate is greater than the industry average, according to NAIC data.
  • Aetna’s 1.16 complaint ratio is greater than the industry average of 1.0. Ratios lower than 1.0 are better.

3. Cigna – HMO Insurance Review

Cigna offers HMO health insurance, among other plans. Cigna is one of the major health insurance businesses in the country.

What made this a top HMO?

Cigna excels among HMO providers and insurance options.

Open Access Plans for HMOs
  • Cigna offers HMO Open Access in several states and regions. This plan combines PPO and HMO features.
  • These HMO insurance plans let subscribers choose a PCP. A PCP is optional for policyholders.
  • Members must see Cigna network providers for coverage.
  • Also includes benefits like dental insurance, vision, and medical

Whether you have Cigna HMO insurance or another plan, you can use myCigna online and as an app. MyCigna lets HMO members check claim statuses and account balances and find a doctor.

myCigna users can learn about their HMO plans, view their claim history, estimate medical expenditures, research hospitals, and use the Quicken Health Expense Tracker.

Costs predicted

Cigna HMO insurance offers certainty in out-of-pocket expenditures, an advantage for many clients.

Their HMO Open Access plans forecast out-of-pocket expenses across treatments, reducing worry about pricing uncertainty.

HMO members know what to spend while seeing a provider.

4. Humana – HMO Insurance Review

Humana is a famous health insurance provider that offers numerous Medicare Advantage plans. HMO consumers must use the company’s network of doctors and hospitals. The cheapest option.

Key Attributes
  • Benefits beyond medical, vision, and dental
  • Internal surveys show high member satisfaction.
  • Good prescription coverage
How It Works

If you have a Humana HMO, you can go to any doctor in the Humana network. Also, if you have Humana, you’re not tied to a certain insurance company but have the freedom to choose your doctor or hospital. Most Humana HMO plans cover prescriptions. Benefits for vision HMO and dental HMO plans are also provided, in addition to hearing aids, which are not covered under original Medicare.

Humana Reviews:
  • All 50 states are included in the coverage.
  • The MyHumana portal is accessible through desktop and mobile apps at all hours of the day.
  • Chronic pain is covered by Humana.

Humana covers all 50 states. Customers can access a wider range of healthcare providers than other insurers.

MyHumana is online and mobile 24/7. Users can look through and print forms, make payments, manage their plan benefits, retrieve their ID cards, and check the status of their coverage or claims. Live chat and an online support forum are also available for clients with employer-sponsored programs.

Humana offers plans for people with chronic pain or other conditions that make self-care difficult. Humana Well Dine, which provides healthy meal delivery to patients undergoing treatment or living with a chronic disease, is one such program.

UnitedHealthcare – HMO Insurance Review

United Healthcare offers medical HMO coverage to individuals, families, and employers. UHC offers short-term, small-business, dental, and Medicare plans.

Factors that made this a top HMO

UHC is a leading HMO provider for several reasons.

Cost Control

UHC focuses on helping members control costs, whether they have HMO insurance or another plan. UHC helps members stay on budget from plan selection through benefit collection.

This HMO leader offers online tools to assist members in evaluating and comparing costs and value.

Preventive Care
  • Preventative care is fully covered if in-network with an HMO from UHC.
  • In-network preventative care appointments have no out-of-pocket fees.
  • UHC offers a large network of hospitals, pharmacies, and doctors around the country.
Health4Me App

All UHC policyholders, including HMO members, can use Health4Me. This app features:

  • The search tool helps identify in-network doctors, hospitals, or clinic
  • Urgent Care or ER can be found nearby.
  • Members can compare costs, read provider reviews, and check account balances.
  • A registered nurse is accessible 24/7
  • The Talk To Me tool can be used to contact a customer care person concerning benefits and claims.

What Is the Cost of an HMO Plan?

Everyone wants to save money on health insurance when purchasing. However, HMOs are expensive, and private insurance costs more. Also, a lot more than a health savings account.

A health insurance plan, such as a private one, requires money to buy, maintain, and serve. Also, HMO plans provide members discounts and other benefits.

An HMO costs $50-$1,000 a year. That doesn’t include membership, monthly payments, or HMO services.

An HMO plan can be pricey, especially if you don’t have much money. Low- or no-cost plans may cost more than private health insurance.

Is an HMO the Right Choice for You?

Your health insurance should fit your lifestyle. If you:

  • You wish to reduce monthly health insurance premiums.
  • You’re comfortable making health decisions with a primary care doctor.
  • You normally stay in your local region to be treated by in-network providers.
  • An HMO may not be the ideal solution if you wish to see doctors outside the network or without a referral.

Bottom Line

Having health insurance is something that everyone should think about. Individual circumstances, such as health, resources, and desired quality of life, should be considered while deciding on the best strategy. HMOs are popular health insurance because they provide inexpensive coverage and emphasize coordinated care. HMOs offer less flexibility than PPOs, but those desiring lower medical expenditures may be content with the tradeoff.

Reach out Today at NewHealthInsurance to learn more about HMOs.


Does an HMO cover out-of-network care?

HMOs don’t cover out-of-network care. Your insurance company will only pay half if you see a doctor or hospital in the HMO’s network.

Also, you must pay the full cost of out-of-network care. The only exception to this rule is emergency care. Even if the facility is out-of-network, emergency room or urgent care services are covered at the standard rate.

Do you require a primary care physician with an HMO?

HMO participants must use an in-network primary care doctor. HMOs require a doctor to manage care and make specialist referrals.

Are HMOs referral-required to consult a specialist?

You need a referral to see a specialist if you have an HMO. Referrals aren’t always needed. To see an obstetrician or gynecologist, women don’t need a recommendation.

Your primary care provider will assess if you need to see a specialist and, if so, which specialist is best for you. Without a reference, your health insurance may not cover a specialist visit.

Which HMO model offers the largest physician selection to its members?

A network-based HMO offers the most provider options. Policyholders have access to more general practitioners, specialists, and hospitals thanks to the network model’s arrangements with multi-specialty groups, solo practitioners, and other independent providers.

Do Health Maintenance Organization (HMO) plans cover prescription medications?

HMOs usually cover prescription medicines. Plan. For Medicare Part D drug coverage, you must join an HMO. You can’t join a Medicare drug plan if you have an HMO without drug coverage.

What else must I know about this kind of plan?

  • Your plan will tell you if your doctor or other provider leaves. You can switch doctors.
  • You may have to pay the entire cost for care outside the plan’s network.
  • Comply with the plan’s requirements, such as obtaining pre-approval before receiving any services.
Get A Free Affordable Health Insurance Quote