Health Maintenance Organizations (HMOs)

20.2.1- Health Maintenance Organizations (HMOs) (Rev. 124, Issued: 11-10-16; Effective: 11-10-16; Implementation: 11-10-16) HMO - An HMO is generally the most restrictive of the CCP types. HMOs may control enrollees’ utilization of services by requiring enrollees to go `through a gatekeeper, usually the enrollees’ PCP, to obtain referrals for services the PCP does not furnish and to obtain all services from network providers (42 CFR 417.448(a)). HMO-POS - Some HMOs offer coverage of certain specified plan-covered services outside of the plan network. Offering that out-of-network access to some covered services requires that the HMO offer a point-of-service (POS) supplemental benefit and may also require the HMO to obtain state licensure to offer an HMO-POS. The HMO- POS must specify in writing which services it offers out-of-network, maximum enrollee out-of-pocket cost sharing, and any annual limits on the benefits offered under the POS benefit.