Frequently Asked Questions - HMO

Q. Am I covered by an HMO if I’m out of town?

A. YES. If you are out of the HMO network area and have a medical emergency, seek immediate care. You are required to contact your PCP or HMO within 48 hours or as soon as possible. However, if you are out of the HMO network and it is not a medical emergency, you must call your PCP or HMO before you seek medical care.

Q. What is a Primary Care Physician (PCP)?

A. A PCP, also called a “gatekeeper,” is a doctor that coordinates all aspects of your medical care. The PCP determines the treatment needed and whether it is necessary to see a specialist. A PCP may be a general or family practitioner, internist or pediatrician.

Q. Do all HMO plans require a PCP?

A. Only Mercy Health Plans in the south central and southwest regions requires the use of a PCP.

Q. Are my dependents and I required to select the same PCP?

A. NO. Each covered person may choose his/her own PCP.

Q. Can I change my PCP during the year? How often?

A. YES. You can change your PCP at any time.

Q. If my PCP or Specialist withdraws from the plan, may I change to a different plan?

A. NO. If your PCP or Specialist withdraws from the plan, another network physician must be chosen. You are not allowed to change plans during the year if a physician leaves the plan. You may change plans only during Open Enrollment.

Q. What happens if the medical service I need cannot be provided through a network provider?

A. You are eligible for such services from non-network providers. These services must be authorized in advance by your HMO plan.

Q. If a member who is not eligible for workers’compensation gets hurt on the job (i.e., a farmer), will he/she be covered?

A. YES.

Q. My doctor referred me to a specialist who is not in the HMO plan’s network. Is this covered?

A. Visits to non-network providers are not covered except in case of emergency care. If required services are not available through a network provider, you can contact the medical plan for prior authorization to a non-network provider. If approval is not obtained, charges are not covered.