HMO PLAN - IN DETAIL

OK..so today's post will focus on the benefits and setbacks of going with an HMO plan and before you decide to enroll in an HMO plan, there are several things you may wish to consider like the different types of HMO, their costs, benefits and their coverage ...as each HMO coverage plan has it's own advantages and disadvantages, You need to do a proper investigation before you make a final decision.

HMOs are also known as health maintenance organizations. Under this type of coverage, you can only see doctors that are members of the HMO.When you sign up, you select a primary physician who will then coordinate all of your medical care. This means, if you need to see a specialist, your primary physician will refer you to that person.

There are 3 types of the HMO, referred to as models; and those are the following:-

• Staff Model - In This model the doctors and nurses are employed directly by the HMO. There is only one location that the insured can go to under this plan in order to receive coverage for their care. There is limitation in the choice of doctors available as they are only able to pick a doctor that is in that particular building. The employees of this model do not provide treatment for anyone that isn’t covered by the HMO plan.

• Group Model - In the HMO group model, the health care maintenance organization will pay the physician group and not pay health care physicians. After receiving the payment from the health care maintenance organization, the physician group will decide how to allocate the money among the individual physicians in the group. The group model has a closed-panel, wherein the group of health care physicians can only provide health care services for HMO health insurance patients.

• Network Model- Now that you know the other two types of models now we are onto the most common type of model; the network model. Within the network model the HMO will contract with either independent physicians or a group of physicians. By the contracting out to the individuals or groups they are able to receive special rates back in turn for their clients. The staff is not limited to just HMO patients as they are able to treat anyone.

The network model is by far the most common, but has some disadvantages compared to the staff or group models. In the staff model, and some group models, doctors have more flexibility, and generally have more resources at their disposal since everything is handled in-house. The network model requires that very particular procedures be followed in order to get tests and specialist appointments, a process that can require significant legwork on the part of both physician and patient.

BENEFITS OF AN HMO PLAN

• lower premiums and out-of-pocket costs.

• emphasis on preventive care

• access to routine check-ups, pap smears, mammograms, immunizations, screening tests, smoking cessation programs and weight loss seminars that are not always covered under traditional fee-for-service health insurance

• can get services from a primary care provider who would know details about the person’s social, financial, family and personal situations. The primary health care provider will then organize the person’s health care in a way in which fewer services will be used.

• no deductible for the patient. The only thing that is required is the prescribed co-payment for services that may run between $15 and $20 a visit.

DISADVANTAGES

• you are only allowed to go to a prescribed list of doctors. This is known as the HMO’s private network and if you do plan to go outside, the HMO will not cover this care.

• If you have used a certain specialist for years, depending on the medical condition; When it comes to see that specialist, you need to be referred by the HMO to see them. If you do not follow this, you may be asked to pay the entire cost of the visit.

Most insurance companies that offer HMO plan can provide you with a directory of participating physicians and hospitals that will help you narrow down your search.

To find an HMO plan in your area, visit the site individual health insurance and choose your state for a list of providers.