Also known as: Health Maintenance Organization, HMO plan
An HMO is a managed-care health insurance plan that requires members to receive covered services from a contracted provider network, usually coordinated through a primary care physician (PCP) who issues referrals for specialists. In exchange for the tighter network, HMOs typically charge lower premiums and predictable copays.
A family in Texas pays $412 a month for an HMO. When their child needs a dermatologist, the PCP first issues a referral. Because the specialist is inside the network, the visit costs a flat $35 copay instead of the $220 the same visit would run under a PPO out-of-network claim.
Choosing an HMO can cut monthly premiums by 15 to 30 percent compared with a PPO of similar actuarial value, but it also restricts choice. Understanding the network rules before enrollment prevents surprise bills and denied claims — the two most common triggers of consumer disputes filed with state insurance departments.
You pick a primary care physician from the plan's network at enrollment.
Your PCP must issue a referral before an in-network specialist visit is covered.
Care outside the contracted network is not covered outside of a true emergency.
Most visits carry a predictable copay instead of coinsurance percentages.
How ERISA governs most U.S. employer health plans in 2026, the deadlines that apply after a denial, when external review helps, and when to hire an ERISA attorney before filing in federal court.
A source-based 2026 guide to COBRA continuation coverage: qualifying events, election deadlines, true premium costs, ACA alternatives, employer notice duties, and enforcement of ERISA rights.
A neutral, source-based 2026 guide to Medicare Advantage denials: prior authorization rules, the five-level appeal process, expedited review, new CMS coverage rules, and when to hire an elder-law attorney.
