HMO - Health Maintenance Organization

What is an HMO?
Health Maintenance Organization Network of health care providers includes doctors, hospitals, pharmacies and other medical facilities and professionals The network works together to manage the quality and cost of each member's health care.

How does an HMO work?
Each HMO member selects a Primary Care Physician (PCP) from a directory of participating physicians in the areas of general practice, family practice, internal medicine or pediatrics.

The PCP will coordinate all of the member's health care needs. If the PCP can effectively provide care, he will. If he determines a specialist is needed, he will refer the member to a Participating Specialist in the HMO Network.

Advantages of an HMO?
Advantages of an HMO? Members enjoy lower out-of-pocket-expenses compared to traditional Indemnity medical insurance. Visits to the doctor's office, hospital charges and many other medical care expenses are covered at 100% after a small copayment such as $5 or $10 per visit. Generally, prescription drugs, routine physicals, lab tests, vision exams, well-baby care and maternity visits are covered. Do not require you to pay an annual deductible before services are covered. No lifetime maximum. They take care of most paperwork, so members do not have to complete claim forms.

Are there any drawbacks to an HMO?
Some people who are accustomed to selecting their own health care providers and facilities find working with a Primary Care Physician system to be inconvenient or restrictive at first. HMOs are constantly changing however, due to competitive pressures. Some companies are less restrictive in allowing you to see a specialist. HMO members who recognize the cost-savings, quality care and conveniences they enjoy with managed care are generally satisfied with the tradeoff.

No benefits are paid if a member decides to go to a health care provider that is not in the network.

Questions to ask about this health plan.

Are there many doctors to choose from?
Do you select from a list of contract physicians or from the available staff of a group practice?
Which doctors are accepting new patients?
How hard is it to change doctors if you decide you want someone else?
How are referrals to specialists handled?
Is it easy to get appointments?
How far in advance must routine visits be scheduled?
What arrangements does the HMO have for handling emergency care?
Does the HMO offer the services you want?
What preventive services are provided?
Are there limits on medical tests, surgery, mental health care, home care, or other support offered?
What if you need a special service not provided by the HMO?
What is the service area of the HMO?
Where are the facilities located in your community that serve HMO members?
How convenient to your home and workplace are the doctors, hospitals, and emergency care centers that make up the HMO network?
What happens if you or a family member are out of town and need medical treatment?
What will the HMO plan cost?
What is the yearly total for monthly fees?
In addition, are there copayments for office visits, emergency care, prescribed drugs, or other services?
How much?