This type of health plan provides the most comprehensive level of coverage with the lowest share of cost passed on to the insured. Health Maintenance Organizations (HMO) are considered “pre-paid,” meaning that you pay for your health care in advance in the form of a monthly premium. There may be small co-payments required for some covered services, such as office visits and prescription drugs, which must be paid to the health care provider at the time service is provided. The monthly fees remain the same, regardless of types or levels of services provided and doctor’s visits are the same co-payment regardless of most of the medical treatments provided. Greater varieties of affordable HMO health insurance plans are appearing, many of which require an annual deductible be met for some covered services, as a result of rising health care costs. The HMO plan with a $10 office visit and 100% hospital services still exist, but it is becoming scarce in relation to HMO health ins plans that require higher co-payments and deductibles.
Any medical treatment under an HMO plan must be received within the network of physicians that is operate by the insurance carrier, or from a medical group that has a contract to provide health care for that insurance company. These medical professionals are paid a monthly capitation fee by the insurance company for accepting new members under the HMO plan and must provide you with the required care that is outlined in your HMO plan contract. Except for some medical expenses, such as emergency medical treatment, services you receive outside of this specified network of physicians and medical facilities will not be covered. With an HMO plan, you choose a primary care physician that oversees all of your health care needs and and make any necessary referrals to specialists within his medical group.
Since these physicians that are under contract with the individual health insurance company receive a fixed monthly capitation fee from the insurance company, it is in their best interest to keep your health care costs down. The health care costs and repeat and regular visits from plan members are absorbed by the physician or his medical group, even if the cost of treatment exceeds his compensation from the insurance company. For these reason, many affordable HMO health insurance plans focus on preventive health care and regular screenings in order to catch a treat an illness quickly. It is important to understand the limitations of your HMO plan on what medical expenses are not covered. There may be exclusions or limitations on such things as chiropractic care, mental health disorders and maternity coverage. It is also important to select a primary care physician with whom you are comfortable in allowing him to make decisions regarding your health.
Members of an HMO plan are not required to file claim forms because all health care and dealings with the insurance company are handled by the physician or the medical group. If pre-authorization for treatment is required, this is also handled by the medical group. Many physicians make accept multiple HMO plans from and are not exclusive to any one insurance company. Although under contract with the individual health insurance company, they operate independently. These types of medical groups are referred to as individual practice associations, or IPA’s.
Before you decide to enroll in an HMO plan, there are several things you may wish to consider or investigate. Most importantly, you will need to make sure that the HMO plan provides a network of physicians within your geographical location. Most HMO health ins plans require that you choose a primary care physician whose office is within 30 miles from your home or office. If you have a current physician, contact his office to ask if they accept the HMO plan that you are considering. If they do not, you will be required to change doctors with your new health plan. If you need to choose a new doctor, ask them how accessible treatment is through their offices and what is the average wait time to be seen by a physician for routine health care. Some medical groups are crowded with patients and it could take several days to get an appointment. Some medical groups operate express care facilities with extended hours and allow walk-in visits. These are very useful when you are part of a medical group that takes a long time to get you an appointment.
You will also want to find out which hospitals are limited to under your HMO plan. If you are specific about the hospital you wish to use in the event of a more serious illness or injury, try to find a medical group that uses that hospital as part of their HMO network. Most insurance companies that offer and HMO plan can provide you with a directory of participating physicians and hospitals that will help you narrow down your search. These directories are usually available online, but can also be requested in printed format.