Health Maintenance Organization (HMO)

A Health Maintenance Organization (HMO) is a health insurance plan that requires you to use doctors and facilities within its network. You’ll choose a primary care physician (PCP) who coordinates your care — and in most cases, you need a referral from your PCP before you can see a specialist.

HMOs typically have lower premiums and lower out-of-pocket costs than PPOs, which makes them a strong value if your preferred providers are in the network and you don’t need frequent specialist access.

The tradeoff: outside of emergencies, HMOs generally won’t cover out-of-network care at all. If you see a provider outside the network without authorization, you’ll likely pay the full cost yourself.

HMO is a good fit if:

You want lower monthly premiums
Your doctors are already in the HMO network
You’re comfortable with a PCP coordinating your care
You rarely need to see specialists or out-of-area providers

HMO may not be the right fit if:

You have established specialists you want to keep
You travel frequently and need coverage away from home
You prefer direct access to specialists without a referral

Frequently Asked Questions

What’s the difference between an HMO and a PPO?

An HMO requires you to stay in-network (except emergencies) and typically requires referrals for specialist care. A PPO gives you flexibility to see out-of-network providers and doesn’t require referrals — but costs more in monthly premiums. If your priority is lower cost and your providers are in-network, an HMO is usually the better value.

Does an HMO cover out-of-network care at all?

Emergency care is always covered, even out-of-network, on an HMO plan. Federal law requires all ACA plans to cover emergency services regardless of network status. For non-emergency out-of-network care, you’ll typically pay the full cost yourself unless your plan includes specific exceptions.

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