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What are my responsibilities as an Enrollee?

The purpose of this webpage is to help you learn about an HMO plan enrollee's responsibilities in relation to obtaining covered health care services.

A person who is covered under a health care plan that is issued by a health maintenance organization (HMO) is called an "enrollee." An enrollee's primary responsibility is to know how their HMO plan works. The document that specifically describes how the HMO plan works is called the " evidence of coverage (EOC)." As an enrollee, you should read the EOC thoroughly and become as familiar as possible with the information contained in it. The EOC must be clear and complete and must include information about:

  • Benefits & Limitations
  • Obtaining Services
  • Complaints & Appeals

Under many HMO plans, an enrollee must select a primary care physician/provider (PCP) from the HMO's participating provider list. Most HMO plans require an enrollee to obtain medically necessary covered services through the HMO's delivery Network. An enrollee may receive care outside of the HMO's network during emergencies or instances in which necessary covered services are not available through the HMO's delivery Network. An HMO's Network consists of the physicians and health care providers who have contracted with the HMO. For this reason, an enrollee should be sure that a physician/provider participates in their HMO's Network prior to obtaining services from that physician or provider.

An enrollee is usually required to obtain covered routine care from their PCP as well as ensuring that their PCP has obtained any required pre-authorizations for specialist referrals from the HMO. The enrollee's PCP is responsible for maintaining the continuity of care and for initiating referral (specialist) care for the enrollee through the HMO's Network. As an enrollee, you are responsible for following the arrangements made by your PCP.

An HMO plan must cover Emergency Care 24 hours a day, seven days a week. Except for a copayment requirement, the HMO may not impose any limitations on emergency care services provided in a hospital emergency facility to evaluate and stabilize an enrollee's medical condition. However, an HMO plan enrollee must pay their plan premium and is responsible for paying any applicable copayment to each physician/provider as described in the EOC for each covered service, including each emergency care visit.

Within 30 days of receiving notice of the enrollee's PCP selection, the HMO must issue a member identification card to the enrollee. The member identification card is used to assist the HMO's physicians and providers in identifying the patient as an enrollee of the HMO. As an enrollee, you should always take your member identification card with you to each doctor visit.

There may be times when an HMO's delivery network does not include a physician/provider who is licensed to provide a covered service at the particular time the covered service is medically necessary. When this happens, the HMO must arrange with a non-network physician or provider for the provision of covered medically necessary services. As an enrollee, it is your responsibility to follow the arrangements made by the HMO.

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Last updated: 3/4/2015