How HMOs work

Under an HMO, you must coordinate your care through a primary doctor
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An HMO, or Health Maintenance Organization, takes a different approach to health care relative to the BP Medical Plan options. If you participate in an HMO, all of your health care must be provided by the HMO’s network of providers to receive benefits. You must select a primary care physician (PCP) from the HMO’s network for yourself and for each family member you cover. Your PCP will direct your care, including providing referrals to see a specialist. If you want to change to a different PCP, you need to contact your HMO.

You have the right to designate any PCP who participates in the HMO’s network and who is available to accept you or your family members. For children, you may designate a pediatrician as the PCP. Women do not need to obtain authorization from their HMO or PCP to obtain access to obstetrical or gynecological care from HMO network providers who specialize in obstetrics or gynecology.

Some HMOs do not provide coverage for domestic partners. If you want to cover a domestic partner, be sure to call the HMO’s member services department for information before you enroll in the plan. Contact information for the available HMOs is available through the LifeBenefits site.

If you see a health care provider who is not affiliated with the HMO or receive medical care without the proper referrals, no benefits will be paid.

If you are enrolled in an HMO and have benefit questions, contact your HMO’s member services department for answers at the phone number listed on your HMO ID card.

You may also request a booklet describing your HMO’s general rules and services. Be aware that covered services and treatments may vary from HMO to HMO and may be different from those provided by the BP Medical Plan.

HMOs are subject to the same rules regarding health care claims that apply to the BP Medical Plan. Therefore, the HMO’s rules and procedures must be no less beneficial to HMO participants than the rules that apply to claimants under the BP Medical Plan. Because HMOs are generally insured, they may be subject to claims and appeals rules and procedures under applicable state laws that provide participants even greater potential procedural protections. Contact your HMO for its rules and procedures regarding health care claims.


What else you should know about HMOs

HMOs are independent business entities. The HMO — and not BP — is fully responsible for providing benefits and coverage once the HMO premium has been paid. As a result, neither BP nor the plan administrator can interfere in medical or administrative decisions made by an HMO or direct the HMO in any way regarding benefits or coverage. Therefore, if you and an HMO medical provider do not agree on a course of treatment, you must personally pursue the matter through the HMO's appeals process. Similarly, if an HMO fails to pay its network provider for service you receive, you may be individually liable to pay for such services. Additional financial assistance from BP will not be provided.

 

Publication date: April 2019

 

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