HMO Eligibility

By Employer Benefits, Inc.

June 15, 2022

Health insurance is a hot topic. HMO or the Health Maintenance Organization is certainly one option. There are other options, with varying costs and coverage, so which one is best for you?

People often choose an HMO as the cost is usually significantly less. This works out well for people on fixed incomes or those without health insurance that is provided by their work or spouse.

What is HMO?

As a health insurance company, the HMO provides coverage for medical services. These services are almost always limited to the healthcare professional that you have access to. The doctors work on contracts for these HMOs.

HMOs, require the person to choose their healthcare provider from doctors who are within the network. They provide basic care and can recommend a more specialized doctor if needed.

The doctors are paid through the HMO coverage that you have. The plans available, just like the services, can be limited. For everyday needs, this is often the popular, and satisfactory choice.

HMO Specialized Doctors

How to Become HMO Eligible

In order to become eligible for HMO insurance, you must reside or live within the area each particular plan covers. That means you can have access to health services provided within this specific area.

There are exceptions for people who require emergency or specialized care. But, if there is an HMO in the area where you live or work, then you can get healthcare coverage.

HMO Plans

Not all HMOs are the same. The major differences are the types of services you can get and the cost. Other plans include:

Point of Service

A POS type of insurance plan allows you to seek medical care outside of the network, however, it will cost more. If you need a specialist you will still need to have a referral from your regular healthcare provider.

Prefered Provider Organization

The PPO type of plan is similar to POS in that it allows the person to seek medical help outside the network. It does still cost more but you have the option to choose the provider without the need for a referral.

Exclusive Provider Organization

The EPO option of insurance allows you to use only the medical professionals within their network, but you don’t need approval or a referral to go outside the network. This will cost more but it doesn’t need to be for emergencies only.

How To Choose?

The costs of these plans don’t really vary, so it will come down to the individual’s needs. Most people look at the cost and the available options to make up their minds.

Some people don’t like the restrictions put on them by each network, while others like the ease and low cost of using HMOs. Each situation will need to be based on what the person or family needs.

Pros and Cons of HMO

Choosing an HMO ultimately comes down to what the person needs and can afford.


The biggest advantage is the lower cost. Other types of insurance premiums can be outrageous. This means lower monthly payments, and lower out-of-pocket costs, as well.

Options for health care providers can be vast. You can choose the medical professionals you want from the network.

They also help you coordinate your healthcare, by providing referrals for extra or more specialized care. Visiting your doctor or needing a hospital stay isn’t expensive or a hassle.


Many people find the HMO insurance plan restricting. You need to choose from medical providers within the network, or pay extra.

Out-of-network costs can be very expensive. If you need a doctor in a different city, state, or country, then it can cost a lot.

You can’t just choose a specialist, you need to be referred. If your healthcare provider leaves, you are left to choose another and start the entire process all over again.

Health Maintenance Organization (HMO)

Obviously, HMO insurance coverage won’t be for everyone, but it is effective and convenient for those who desire lower costs in healthcare. It makes seeing your doctor convenient and much easier.

For those who need more specialized care, the HMO approach may not be ideal. There are certainly other options available when it comes to health insurance, so make sure you explore all available options.

Employer Benefits Inc. also known as EBI Insurance is a locally owned and operated health insurance agency, providing top-notch medical insurance services across Reno, Nevada and surrounding areas. Call us today at 775-786-6381.


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