Health Maintenance Organization HMO

The definition of Health Maintenance Organization HMO, and how it fits into the Zenefits Health Insurance Marketplace

What is an HMO?

A Health Maintenance Organization (HMO) plan is a type of medical insurance plan with regulated care that is available to only employees living with its designated network area.


How does an HMO work?

HMO plans require you to designate a primary care physician (PCP). This PCP will need to refer enrollees to any other doctors/specialists in the local network. Think of the PCP as a “gatekeeper” to using coverage and receiving care. HMO plans are not available to out-of-state employees, or employees who live outside of the carrier’s established network area. HMO plans usually cost slightly less per month due to the regulation of care. No out-of-network coverage: services are only covered when performed by in-network providers only (Emergency coverage is the only exception, see: Emergency Coverage).