How an HMO Works
(Health Maintenance Organization)
You have the choice of enrolling in one of three plans: the City of Chicago's Medical Care Plan also known as the PPO plan, the POS plan or an HMO.
An HMO is a pre-paid managed care plan that provides comprehensive medical benefits. When you join an HMO, you choose a provider (clinic or primary care physician) from those participating in the HMO provider network. Your choice of hospitals is limited to those hospitals that are affiliated with the HMO. All of your medical care is directed through the clinic or the primary care physician that you choose, including routine medical care, hospitalizations and referrals for specialized care. The HMO must authorize all services.
If you choose the HMO option for your medical coverage, you will incur few, if any, medical expenses for services provided or authorized by the HMO. Services generally include:
outpatient care in the HMO health center
or HMO
doctor's office;
inpatient care in an HMO-affiliated
hospital;
emergency care;
limited mental health services; and
other services specified by the HMO.
Choose a Plan Once a Year
You may choose to enroll in an HMO during your initial election period. For specific enrollment and eligibility guidelines, see the How To Enroll for Medical Coverage section of this handbook. If you do not join an HMO at that time, you will not have another opportunity to select an HMO until the annual open enrollment period. You can withdraw from or switch to an HMO during the open enrollment period each year.
If you select an HMO and the doctor or clinic you originally chose is no longer available to provide services, you will have to choose another doctor or clinic from the list of providers your HMO offers. You will not be able to change HMOs or select the PPO or POS plan until the next open enrollment period.
Covered Services
The benefit levels for covered services are the same for all the HMO's offered. It is important that you select the plan that offers you and your family the doctors, hospitals and other health care facilities that you would use in case of illness or injury.
The Summary of HMO Medical Plan Benefits chart on pages HMO-1A and HMO-1B describes eligibility and benefits available as of the date of printing. Since this is a summary of key features, you should refer to specific HMO's certificates of coverage for actual terms of the benefits.
Contact the Benefits Management Office if you have any questions about HMO benefits.
Emergency Care is covered for an unexpected injury or illness that occurs outside of the HMO service area while at home or traveling out of state. Refer to your HMO Certificate of Coverage for more details.
November 2002