Managed Care Plans (MCP)
Health Maintenance Organizations (HMO)
An HMO is a Managed Care Plan that provides its members with comprehensive medical care services on a prepaid basis. HMOs require that you choose a Primary Care Physician (PCP) and provider location from those participating in the HMO provider network. The PCP manages your health care treatment by requiring referrals for specialized services. All HMOs have a uniform basic benefit plan; however, some may offer additional benefits or may not include coverage for certain providers, such as chiropractors. Consult the specific HMO for details. All HMOs have unlimited policy maximums. See the FY 2016 State Health Care Plan map (as of July 1, 2015) for the available plans in your area.
Effective July 1, 2015 prescription drug deductibles and copayments you pay will apply to your out-of-pocket maximum; therefore, when you reach your out-of-pocket maximum, eligible medical, behavioral health and prescription drug charges will be covered at 100 percent for the remainder of the plan year.
Points to consider in making this choice:
- The doctor you choose becomes your PCP and all medical care, including routine care, hospitalization, and referral to other health professionals, must be coordinated under the direction of your PCP.
- Preventive and well-care services, such as routine physicals and pediatric care, are provided at no additional cost.
- Co-payments apply to doctor's office visits, prescriptions, hospital admissions, emergency room visits and some other services.
- You generally do not need to submit claim forms, except in cases when emergency care takes place outside of your coverage area.
FY 2016 Benefit Choice Options booklet (as of July 1, 2015)
CMS HMO Overview