Types of Insurance: Health Maintenance Organizations
(HMOs)
Health maintenance organizations are prepaid health plans. As an
HMO member, you pay a monthly premium. In exchange, the HMO provides
comprehensive care for you and your family, including doctors' visits,
hospital stays, emergency care, surgery, lab tests, x-rays, and
therapy.
The HMO arranges for this care either directly in its own group
practice and/or through doctors and other health care professionals
under contract. Usually, your choices of doctors and hospitals are
limited to those that have agreements with the HMO to provide care.
However, exceptions are made in emergencies or when medically necessary.
There may be a small copayment for each office visit, such as $5
for a doctor's visit or $25 for hospital emergency room treatment.
Your total medical costs will likely be lower and more predictable
in an HMO than with fee-for-service insurance.
Because HMOs receive a fixed fee for your covered medical care,
it is in their interest to make sure you get basic health care for
problems before they become serious. HMOs typically provide preventive
care, such as office visits, immunizations, well-baby checkups,
mammograms, and physicals. The range of services covered vary in
HMOs, so it is important to compare available plans. Some services,
such as outpatient mental health care, often are provided only on
a limited basis.
Many people like HMOs because they do not require claim forms for
office visits or hospital stays. Instead, members present a card,
like a credit card, at the doctor's office or hospital. However,
in an HMO you may have to wait longer for an appointment than you
would with a fee-for-service plan.
In some HMOs, doctors are salaried and they all have offices in
an HMO building at one or more locations in your community as part
of a prepaid group practice. In others, independent groups of doctors
contract with the HMO to take care of patients. These are called
individual practice associations (IPAs) and they are made up of
private physicians in private offices who agree to care for HMO
members. You select a doctor from a list of participating physicians
that make up the IPA network. If you are thinking of switching into
an IPA-type of HMO, ask your doctor if he or she participates in
the plan.
In almost all HMOs, you either are assigned or you choose one doctor
to serve as your primary care doctor. This doctor monitors your
health and provides most of your medical care, referring you to
specialists and other health care professionals as needed. You usually
cannot see a specialist without a referral from your primary care
doctor who is expected to manage the care you receive. This is one
way that HMOs can limit your choice.
Before choosing an HMO, it is a good idea to talk to people you
know who are enrolled in it. Ask them how they like the services
and care given.
Questions to Ask About an HMO
- 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 I 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?
"Health Maintenance Organizations (HMOs)"
U.S. Department of Health & Human Services, March 31, 2007
http://www.ahrq.gov
<http://www.ahrq.gov/consumer/insuranc.htm#head14> |
