What is an HMO insurance policy?
HMO plans are managed care health insurance policies that offer coverage for doctors, hospitals, and other healthcare providers. HMOs are typically the least expensive option among health plans because they have lower premiums and limit enrollee out-of-pocket costs by limiting or eliminating deductibles or co-payments when visiting HMO contracted providers. HMOs also require enrollees to choose a primary care physician (PCP) who will help coordinate and manage their care. HMOs generally do not cover out-of-network (non-HMO contracted) providers, so it’s important for enrollees to become familiar with HMO network provider locations.
When do you need a referral?
HMO plans require referrals for non-preventative healthcare services. Referrals are necessary to be covered under HMO policies. Your primary care physician (PCP) must provide a written referral before you can visit specialists or receive other medical services. HMOs may not cover the costs related to visits to out-of-network providers and treatments without a referral. HMOs also typically require pre-authorization for certain types of treatments and services to be covered.
Is there a wavier?
HMOs do not offer waivers, but they may provide exceptions in certain situations. HMOs may provide coverage for out-of-network care on a case-by-case basis if the plan determines that it is medically necessary to do so. HMO plans also usually have appeals process in place in which enrollees can challenge HMO decisions. HMOs may also waive certain requirements, such as a referral, if it is determined that the enrollee would incur higher costs or significant delays in care due to not being able to obtain the necessary referrals.