In HMO Plans, you generally must get your care and services from doctors, other health care providers, and hospitals in the plan's network, except:

• Emergency care

• Out-of-area urgent care

• Temporary out-of-area dialysis

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HMO Point-of-Service (HMOPOS) plans are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance. It’s important that you follow the plan’s rules, like getting prior approval for a certain service when the plan requires it. 

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Frequently Asked Questions

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Are prescription drugs covered in Health Maintenance Organization (HMO) Plans?

In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want 

Medicare drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage. If you join an HMO plan without drug coverage, you can’t join a separate Medicare drug plan.

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Do I need to choose a primary care doctor in Health Maintenance Organization (HMO) Plans?

In most cases, yes, you need to choose a primary care doctor in HMO Plans.

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Do I have to get a referral to see a specialist in Health Maintenance Organization (HMO) Plans?

In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don't require a referral.

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What else do I need to know about this type of plan?

• If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.

• If you get health care outside the plan's 

  network, you may have to pay the full cost.

• It's important that you follow the plan's rules, like getting prior approval for a certain service when needed.