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?
