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How Does an HMO Plan Work? 3 Tips for Switching From a PPO to an HMO plan

By June 14, 2016August 17th, 2021Health Insurance
A chart illustrating how HMOs work

If you were covered by a PPO plan in the past and switched to an HMO plan, you may have some questions about how an HMO works. Don’t worry — it’s easier than you think.

What is an HMO Plan?

HMO stands for health maintenance organization. An HMO is a type of health plan that requires you to select a family doctor, often called a primary care physician (PCP). You need a referral from your PCP to see a specialist in the HMO network, such as a cardiologist (heart doctor). Typically, only emergency services are covered if you go outside the HMO’s network of participating providers.’ Learn more about HMO insurance plans from Independence Blue Cross.

Tips for Using Your HMO Plan

Here are the three main things to remember about using your HMO plan:

  1. Choose a primary care physician (PCP)
    Your PCP is your family doc, the one you see for regular check-ups and general health problems. IBX members can choose a PCP by logging in at and selecting the Change Your Primary Care Physician. You can pick any PCP that is in your HMO network. As long as you keep the same PCP, you only have to do this step once.
  2. Get referrals
    While your PCP can treat a lot of health conditions, he or she may also want you to see a specialist for certain issues. For example, you may see a cardiologist if you have high blood pressure. Just remember that you need to get your PCP’s official go-ahead (also called your referral) to see a specialist. Your PCP may recommend one, or you can let your PCP know who you’d like to see as long as the specialist is in the HMO network. Check with your PCP’s office for instructions on how to request a referral. Typically, referrals are good for 90 days, so you will need to request a new referral when it expires. There are some services you don’t need to get a referral for, such as:

    1. OB/GYN (maternity and gynecological care) visits
    2. Mammograms
    3. Mental health treatment
    4. Routine eye care
    5. Emergency care
  3. Visit designated sites
    This rule only applies for labs (like when you need bloodwork), radiology, and certain therapy services like physical and occupational therapy. Whenever you need bloodwork or one of the other services, your PCP will either give you a referral or a prescription for services at the designated site. Contact your PCP for a list of designated sites.

There you have it! Choose a PCP, get referrals, and visit designated sites. You’re on your way to using your HMO like a pro.

Still deciding between an HMO or PPO health plan? Shop and compare HMO plans and PPO insurance plans from Independence Blue Cross to see which type of health plan is best for you.

Information on this site is provided for informational purposes and is not meant to substitute for the advice provided by your own physician or other medical professional. You should not use the information contained herein for diagnosing or treating a health problem or disease, or prescribing any medication. If you have, or suspect that you have, a medical problem, promptly contact your health care provider.


Paula Sunshine

About Paula Sunshine

Paula Sunshine is senior vice president and chief marketing executive at Independence Blue Cross. She oversees all commercial and consumer marketing activities, including digital assets such as and the IBX mobile app. Ms. Sunshine earned a bachelor of arts degree in mathematics from Emory University and a master of business administration from the Wharton School at the University of Pennsylvania.