Primary care doctor: In most HMOs you must select a main doctor, called a primary care physician, or PCP. This doctor gives you most of your care and refers you for other services when you need them. Usually, you must see this doctor first before you can see a specialist. Your primary care doctor must be in the HMO’s network.
Medical group: Your medical group is the group of doctors and other providers that your primary care doctor is in. The medical group has a contract with the HMO to provide your care.
Networks and medical groups: Each HMO has a network of doctors, medical groups, labs, hospitals, and other providers. You must get approval from your HMO to get care from a provider outside the network, unless it’s an emergency, or you need urgent care and are outside your plan’s area. Most of the providers you see are also in your medical group.
Check with your HMO about its network of providers. Ask the plan for a copy of its provider directory. Or look on the plan’s website.
Referrals and pre-approval: You must have a referral to see a specialist or get most other services. Your HMO or medical group must approve many of your services before you can get them. Usually it is your primary doctor who gives you a referral and asks for pre-approval.
Check with your HMO about its rules for referrals and pre-approvals. Ask the plan for a copy of its Evidence of Coverage. Or look on the plan's website.
If you have Medicare or Medi-Cal, you may get your services through an HMO.
- Medi-Cal Managed Care plans are for people with Medi-Cal.
- Medicare Advantage is for people with Medicare. Many plans under Medicare Advantage are HMOs. There are also Medicare Advantage PPO plans.
What is a PPO