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Common misconceptions about the HMO network

Sort fact from fiction

This article was last updated Aug. 31, 2021.

"I won't be able to get the kind of care I need."

"I can't make an appointment with the doctor I want to see."

"I won't have any out-of-state coverage."

Are these types of statements about a health maintenance organization (HMO) network swirling in your head?

An HMO network gives you access to doctors and hospitals in a specific area and only covers out-of-network care in emergencies. You might also hear an HMO network referred to as a state-based network. It's no secret that HMO networks of the past had a bad reputation. And, with so many misconceptions about this type of network, it's no wonder there's confusion. So, let's set the record straight.

Top-six HMO myths

Myth: HMO network plans don't have many providers, so I won't be able to go to my local doctor.

Fact: If you have a state-based HMO plan and need care in Iowa, there's a good chance you're covered.

The network spans all of Iowa's 99 counties, including 100 percent of hospitals in the state and 98 percent of doctors. Plus, some providers in the counties that border Iowa are considered in-network, too.1

HMO networks come in all shapes and sizes. One of the best ways to keep your health care costs down is to choose an in-network provider. Find a doctor by logging in to myWellmark® Opens New Window.

Wellmark's state-based HMO network does not include the Wellmark ValueSM Health Plan HMO Network.

Myth: HMO network plans don't cover any chiropractor visits.

Fact: In-network chiropractors are covered on Wellmark's HMO plans.

Almost 400 chiropractors are in Wellmark's state-based HMO network. To find one in your area, log in to myWellmark Opens New Window.

Myth: I need a referral from my personal doctor, also known as a primary care provider (PCP), any time I want to see a specialist.

Fact: HMO network plans may not always require a referral.

You may be able to go to any in-network provider — including specialists and chiropractors — without a PCP referral and without paying extra. That means an HMO network plan can give you the freedom to go to any in-network provider directly. Just be sure to log in to myWellmark to check your benefits before receiving services. 

Myth: HMO out-of-network coverage doesn't provide benefits in the event of an emergency.

Fact: With an HMO, emergency care is covered if you're traveling outside of Iowa. 

If you're experiencing a medical emergency, it's important that you get the care you need. That's why HMO network plans still provide out-of-network coverage in the event of an emergency. As a Wellmark Blue Cross and Blue Shield member, you have nationwide access to more than 96 percent of hospitals and 95 percent of doctors and specialists.Log in to myWellmark Opens New Window to find a participating hospital in your area. 

If you're feeling a little under the weather while traveling and want to avoid an emergency room visit, check out the Doctor On Demand External Site® app, where you can see and talk with a board-certified doctor. Your virtual doctor can treat most common medical conditions, and even prescribe medication if needed. A virtual visit through Doctor On Demand is an affordable option covered by some Wellmark plans. You can also purchase a virtual visit without using your insurance information.

Myth : HMOs never allow access to out-of-network providers and services.

Fact: If you have an HMO, out-of-network care may still be available with special approval. 

If the care you need is not available within the HMO network, talk to your in-network provider about making a request for out-of-network care. This can be done on your behalf before receiving out-of-network care.

Myth: HMOs don't work for families with college students and snowbirds.

Fact: Dependent children attending college, long-term travelers and families living apart may be covered through guest membership.

Guest membership provides benefits for eligible people living out of state for at least 90 days, but you have to sign up before leaving.

Need more explanation about health insurance and how it works? Take 10 minutes to understand your coverage.

Wellmark Blue Cross and Blue Shield network numbers as of May 2020.

2 Consortium Network Compare Findings as of September 2019.