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Marketplace News

What Is an HMO Insurance Plan and How to Use It

Woman Holding White Ceramic Mug At Desk
Photo by Jopwell

During 2023, many people found that most plans offered on the Marketplace in Central Florida were HMOs (Health Maintenance Organizations). HMOs were developed in the early 1970s to help contain the growing cost of medical care in the United States. HMOs generally require members to see only in-network doctors and require you to have a referral from the Primary Care Provider (PCP) before visiting a specialist. There are exceptions often for gynecology, dermatology, and behavioral health. 

Some HMOs assign their members a PCP; the provider’s name is listed on the insurance card. This year we have several new HMO plans offered in our area, but members were not consistently assigned a PCP, causing some confusion. 

If you are unsure who your assigned PCP is or if you want to change your PCP, you need to contact the insurance company directly. Call centers sometimes have long wait times, so we recommend that those who have access to the internet create an online account and try to change their PCP online themselves. The ability to do this varies by the insurance company. 

Navigators can help clients walk through this process online or help a consumer call the insurance company to either find or change their PCP. 

We always encourage our consumers to make an appointment with the PCP as soon as possible, especially if they are new to the insurance. Schedule your annual physical now. When I moved to Central Florida over ten years ago, I reached out to a PCP in January, and the first appointment for a physical was not until May. Before May, I needed to see the doctor for a sick visit, and even though I had never visited the office before, I was considered an “established patient” due to the fact that I had scheduled my annual physical. They were able to squeeze me in for an appointment the next day. 

I once had a young, healthy client who went to the Emergency Room with chest pains. Upon discharge, she was referred to a cardiologist. But she could not schedule with the cardiologist covered by her plan without a referral from her assigned PCP. She had never bothered to see the PCP because she hadn’t been sick. It took several weeks to get an appointment with the PCP, which delayed her care with the cardiologist. If she had had an established relationship with a PCP, that provider would have reviewed the reports from the Emergency Department and made the referral to the cardiologist immediately.

Anne Packham

Anne Packham

Marketplace Project Director
[email protected]

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You may qualify for year-round Health Insurance Marketplace enrollment, if your household income is no more than:

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$26,130 for a family of 2
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