A Health Maintenance Organization (HMO) health plan offers a local and sometimes limited network of doctors and hospitals for you to choose from.

HMO plan important key features:

• You will need to select an in-network primary care provider (PCP) for yourself and your covered dependents. You can change your PCP at any time.
• The PCP you choose will coordinate your health care needs and refer you to specialists as needed, except for OB/GYN (OB/ GYN and PCP must be in the same medical group) and chiropractic services.
• You do not need a referral from your PCP to see a mental health provider; however, you will need to call Aetna directly to speak with a mental health team member 877.204.9186 who will refer you to an in-network mental health provider or confirm if your specific mental health provider is in-network.
• Aetna may need to pre-certify hospitalizations and other outpatient care, but there’s no paperwork for you when using in-network providers.

Yes, you and your covered dependents can only see a provider within the AETNA HMO network.  

If you get medical care outside of the plan’s network (such as a physician, hospital, clinic or pharmacy), those out-of-network services will only be covered if the treatment is considered an emergency or urgent care as defined by your health plan documents.

HMO CALIFORNIA ONLY:

• • Click HERE for the Aetna HMO network.
  • Continue as a guest: Enter a 5-digit zip code or city.
  • Click “Medical Doctors & Specialists”.
  • Click “All Primary Care Physicians,” and the provider listing will appear.
  • Your provider listing will include specific providers currently accepting your Aetna Health Plan. You must call and check with the provider before scheduling your appointment or receiving services to confirm if they are still participating in Aetna’s network.

Most HMO plans are very attractive because of their inexpensive costs for the participant. Most services can be paid with a small copay and there is usually no deductible or a very small deductible. It is important to know the difference between an HMO and a traditional PPO plan to determine if the HMO plan is right for you and your family.

One of the differences between an HMO and a traditional PPO is how service/care is provided or managed. With an HMO, you are not able to be seen by specialists or other service providers without seeing your primary care provider first. Your primary care provider must refer you to see a specialist. HMO plans may also have to pre-approve certain hospital and out-patient care as well. With a traditional PPO, you are able to see any provider you would like without having to go through your primary care provider first.

Another difference is the access to care. With traditional PPOs, they usually have a bigger network which means more access to in-network providers and hospitals/clinics. There is a better chance that your current provider is covered under a PPO network. An HMO plan generally has a much smaller network which means access to a provider of your choice or hospital/clinic is much more limited and sometimes not available in your area. 

When comparing the HMO plan and the PPO plan to determine if the HMO plan is right for you, an HMO may be right for you if the cost savings is more valuable to you and your family and you do not mind taking extra steps to access specialty care along with maybe having to choose a new primary care provider.