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 plan from Blue Care Network, since they work differently than the coverage you might have had in the past. Here are some key steps you should take to get to know your HMO plan and better manage your health care:

  1. Learn how an HMO works. As an HMO (Health Maintenance Organization), Blue Care Network works 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 an illness or more serious injury, your starting point is your primary care physician. That’s why it’s important that every HMO member selects 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, and when you may need one. With an HMO, you’ll sometimes hear the term “referrals.” Your primary care physician typically provides and manages all your care. However, there may be times where you need specialty care. If you do, you may need approval 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.

Note: Visits to specialists who are not in your plan’s network aren’t covered, unless medically necessary or you have a plan that allows you to pay more when you see a doctor outside your network.

Log in to your member account at bcbsm.com or use our app to see when your referral is approved or when it expires.

  1. Understand what’s covered by your HMO. Coverage starts with preventive services that keep minor problems from turning serious, including special programs to help you reach your health and wellness goals. Benefits also include care you need when you’re sick or injured, ranging from office visits and lab tests to hospitalization. Check your member account to find out the specifics of your Blue Care Network coverage.
  2. Double-check your plan’s network. BCN plans are built around a network – a group of providers (doctors, hospitals and other type of health care providers) that are contracted with us to provide certain health care services. Knowing your plan’s network 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 out of network, except in an emergency. You need to make sure the doctor you’ve selected is part of your plan’s network. You can do this by using your member account or our app.

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 our Facebook page.

And check out these other blogs for more about understanding your medical plan:

Photo credit: NIH Clinical Center

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