How HMOs Work

How It Works

An HMO is a structured group of local doctors, hospitals, health care providers and administrators organized to deliver comprehensive medical care to its members at pre-negotiated fees.

As long as your care is coordinated by your Primary Care Physician, an HMO generally covers 100% of the cost for approved care – some plans may require Copayments. Coverage includes preventive care such as physicals, mammograms, gynecological exams, well-child care and immunizations, and prescription drugs. Some HMOs offer limited vision care benefits. There are no claim forms to file and no Deductibles, reasonable and customary limits or Out-of-Pocket Limits.

In most cases, you must use your HMO’s doctors and hospitals to receive benefits. If you go to a doctor or Hospital outside your HMO for care without prior approval, you will not receive any benefits from the plan, except for emergencies (see In an Emergency). Contact your HMO for the locations of your HMO’s medical facilities. The HMO furnishes HMO provider directories without charge as a separate document. HMO provider directories are also available at the following websites: www.bcbsil.com and www.humana.com.

While this Summary Plan Description summarizes the major provisions of this plan, it does not provide you with every plan detail. The plan documents, which govern this plan, provide full details. If there are any discrepancies between this Summary Plan Description and the legal plan documents, the legal plan documents control.