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Health Maintenance Organizations

Members who elect an HMO plan will need to select a primary care physician (PCP) from a network of participating providers. A PCP can be a family practice, general practice, internal medicine, pediatric or an OB/GYN physician. The PCP will direct all healthcare services and will make referrals for specialists and hospitalizations. When care and services are coordinated through the PCP, only a copayment will apply. There are no annual plan deductibles for medical services obtained through an HMO.

The minimum level of HMO coverage provided by all plans is described on the benefit charts below. Please note that some HMOs provide additional coverage, over and above the minimum requirements.

If a member is enrolled in an HMO and their PCP leaves the HMO plan’s network, the member must choose another PCP within that plan. Alternatively, if CMS determines the plan’s network experienced a significant change in the number of medical providers offered, the member may change health plans (the request to change health plans must be elected within 30 days of the qualifying event).