This short video explains benefits, deductibles, copays, coinsurance, and out-of-pocket maximums so you can make the right decisions. (Video, 3:15)Open video transcript
HMO plan basics
What is an HMO?
An HMO is a type of health plan where you receive care within a specific network of doctors and hospitals. Some things to know:
- HMO plans require you to pick a primary care physician, also known as a PCP, who is part of that network. Think of your PCP as your point person. He or she provides all your basic health care services.
- HAP doesn’t require HMO members to get a referral to see an in-network specialist for initial consultations. However, a specialist may require a treatment referral from a member’s primary care physician. Sometimes, a doctor will suggest a procedure that requires prior authorization, which means the request needs to be reviewed to ensure the service is medically necessary. The member’s primary care doctor or specialist can request prior authorization from HAP.
- You have the freedom to see your HAP dermatologist or allergist without referrals. In fact, in our provider network, many specialty office visits don’t require referrals from your PCP. These specialties include:
- Routine labs
- Standard X-ray
If you do need a preauthorization (often called a “referral”) before you get a service, our paperless referral system makes the process hassle-free. Your PCP does all the work for you. You simply show up at your appointment, and your referral will have already arrived.
Coverage that travels with you
With worldwide coverage for emergencies and urgent care, plus an emergency travel assistance program through Assist America, you won't have to worry when you leave home. No matter where you go, urgent care and emergency services are covered if you get sick or hurt.
HAP UAW Trust service area
In addition to worldwide emergency and urgent care coverage, you can seek care in any of the following counties:
- St. Clair
Students away at school
Members who have children who are away from home at school can rest easy knowing they are covered. Children ages 17 to 25, who go to school outside HAP’s coverage area, are covered for emergencies and urgent care.
While students are away at school, common medical services are treated as in-network service, with prior approval. Services such as:
- Required maintenance visits for chronic conditions as authorized by HAP
- Allergy injections
- Prescription coverage as allowed under the member’s prescription medication rider
- Routine immunizations or vaccines according to the recommendations from the Centers for Disease Control and Prevention
Urgent care or ER?
It’s important to know the difference between urgent and emergency conditions to make sure you get the right care at the right time. This can save you out-of-pocket expenses and ensure you’re treated quickly based on your condition.
In most cases it will cost you less out-of-pocket to visit an affiliated urgent care center than an emergency room.
Here’s a convenient infographic showing where you should go if you are ill or hurt.
A deductible is a fixed amount of money you have to pay annually before HAP begins paying its portion of your medical costs. Generally, prescription drugs and medical services covered by a flat copay do not count toward the deductible. All other covered services without copays count toward the deductible.
A health insurance deductible works similar to auto insurance. Let’s say you are involved in an accident. First, you have to pay your deductible amount, and then your insurance company pays for the rest for the repair work. Health insurance deductibles work the same way.