Learn About the Affordable Care Act

Health Maintenance Organization

A health maintenance organization (HMO) is a managed care health insurance plan that provides comprehensive care while trying to control costs.

HMOs require members use a limited network of health care providers. HMOs negotiate set prices with the providers. In some HMOs, rates are capitated, or paid based on the number of people enrolled. Others are fee-for-service or paid based on the number and type of services provided.

HMOs also require members to have a primary care physician (PCP) who coordinates their care.

They may limit which doctors can serve as a PCP or require the PCP to give you a referral before you can see a specialist. HMOs also may require they review and approve non-routine care before it is provided.

Enrollees often have co-pays for many procedures. If they use an out-of-network provider, except in emergencies, members often must pay the full cost of care.

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