Health Maintenance Organizations(HMO)
One of the most well-known prepaid health plans is an HMO, or health maintenance organization. As a member of an HMO, you pay a monthly fee in exchange for comprehensive health care services for you and your family. This seeks to limit costs for the patient, but within a strict framework of participating doctors and hospitals.
What does an HMO provide?
Most HMOs set out a plan which includes covering costs for hospital stays and consultations with the doctor, certain emergency health care, tests (including x-rays), surgery and necessary therapy. These services are either covered within the HMO’s own practice or with doctors and professionals contracted to the organization. This means that your choice is usually limited to hospitals, doctors and practices that have an arrangement with the HMO, though exceptions can often be made if there is an emergency or the illness necessitates treatment outside the HMO’s coverage.
Does coverage vary between HMOs?
Different HMOs offer different sorts of plans, so it is important to read up on each organization carefully to get a full understanding of their policies. As HMOs are paid a fixed fee by their members, they have a vested financial interest in treating health care issues before they become major. This allows them to keep costs low, and means that they specialize in preventative care including doctors’ visits, physical checkups, immunizations, mammograms etc.
Always research your prospective HMO’s policies on more involved procedures, plus emergency and serious care, and compare available schemes. (For instance, mental health care is usually limited on these plans, and small co-payments may be charged for emergency room care.)
No claim forms
As opposed to many options, HMOs eliminate the need for claim forms when visiting the doctor or hospital. Instead a card is provided by the HMO to let the site know you are part of the scheme. But this might also mean that you wait longer periods for a doctor or hospital appointment than patients on a traditional fee-for-service insurance plan.
Choosing your doctor
Depending on the HMO, doctors work for the organization in one of two ways. They are either paid by the HMO and located in one or more HMO centres in your local community, or are private doctors with an HMO contract agreeing to care for members. In the latter case, these private physicians are part of an individual practice association (IPA), and you can choose from a list of doctors who are part of the network. Your existing doctor may be part of this network, so it is worth asking them if you wish to switch to an HMO. Some HMOs will simply assign you a primary care doctor. In an HMO plan, seeing a specialist can be difficult if you do not receive a referral from your doctor.
Talk to members
If you are considering an HMO, you should first talk to friends or acquaintances with HMO experience, especially those enrolled in your prospective HMO. Ask them about any concerns you have, and if their expectations have been met by the service.