Health Maintenance Organization (HMO) Plans Managing your care can be challenging on your own. To ensure you have the best experience, it is recommended that you select a primary care practitioner (PCP). Your PCP can help coordinate overall medical care and is the main point of contact for your health care. They work with other health care professionals, such as specialists, when necessary.
HMO PLANS OFFER:
FREE PREVENTATIVE CARE. 100% coverage for preventive services, such as annual exams, screenings, and more, when performed in-network and coded as preventive. $0 COPAY PREVENTIVE DRUGS. There is no cost associated with select preventive drugs that target common medical conditions, such as high blood pressure and diabetes. AFFORDABLE ACCESS TO ASPIRUS NETWORK PROVIDERS. Convenient access to Aspirus Health Plan's Signature Network plus many health care professionals and hospitals in your area. First Health functions as a wrap network to help lower out-of-pocket costs for emergency services in the 49 states outside of Wisconsin.
With an HMO, you must get health care from in-network health care providers. If you receive care from an out-of-network provider, the HMO plan will not pay for that care unless prior authorization was approved or the condition was deemed an emergency.
If the prior authorization is approved or you seek care from an out-of-network emergency room, the non-participating reimbursement value will apply to out-of-network providers and services. The amount the plan pays is the allowed amount for any covered service. But if an out-of-network provider charges more than the allowed amount, you may have to pay the difference.
Here's an example: You go to an out-of-network hospital, which charges $1,500 for an overnight stay. If the allowed amount is $1,000, you may have to pay the $500 difference.