What to know about HMOs

Everything You Need to Know About HMOs

Educating yourself about your health care plan can help you make informed decisions and get the most out of your coverage. This is especially true if you have an HMO like Blue Care Network, since they work a little differently than the plans you might have had in the past. Here are some key steps you should take now to get to know your HMO and better manage your health care:

  1. Learn how an HMO works. As an HMO (it stands for Health Maintenance Organization), Blue Care Network contracts with physicians, hospitals and other medical professionals to provide you with a variety of health care services. Whenever you need care, whether it’s a routine checkup, immunization, or treatment for strep throat or more serious injury, your starting point is your primary care physician. This is why every HMO member needs to select one. He or she is responsible for managing all the care you receive, from providing preventive health services to treating your illness to writing referrals and coordinating your care with specialists.
  2. Know what a referral is. With an HMO, you’ll sometimes hear the term “referrals.” Your primary care physician typically provides and manages all of your care. However, there may be times where you need specialty care. If you do, you may need special approval from your primary care physician for certain services and to see specialists. If the service requires a referral and your primary care physician or OB-GYN doesn’t refer you, you may be responsible for the costs. Unless medically necessary or you have a plan that allows you to pay more when you see a doctor outside your network, visits to specialists who aren’t part of your plan’s network aren’t covered.
  3. Understand what’s covered by your HMO. Coverage starts with preventive services that can keep minor problems from turning serious and includes special programs to help you reach your health and wellness goals. Benefits also include the care you need when you’re sick or injured, ranging from office visits and lab tests to hospitalization. Log in at bcbsm.com to find out the specifics of your Blue Care Network coverage.
  4. Double-check your plan’s network. Most BCN plans are built around a network – a group of providers (doctors, hospitals and other type of health care providers) that’s contracted with us to provide certain health care services. Knowing what your plan’s network is and how it works is important. We have different HMO networks throughout the state. Some are broad and include doctors and hospitals in almost every county in Michigan. Others are small and based in a certain geographic area. Most HMO plans don’t cover care outside the network, except in an emergency. The one exception is if you’re in one of the few plans that allows members to pay more to see doctors outside the network. Whichever plan you have, you need to make sure the doctor you’ve selected is part of your plan’s network. You can do this by using our Find A Doctor tool.

For more information about what to expect with your HMO refer to this flyer and stay tuned for more blogs in our HMO 101 series. For additional health and wellness tips, follow the BCN Facebook page. And check out these other blogs for more about understanding your medical plan:

Photo credit: NIH Clinical Center

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