Getting Started
HMO plans

HMO stands for health maintenance organization. While HMOs have been much maligned over they years, they are in fact a great and affordable way to provide health insurance for you and your family. In reality, HMOs provide you with the most comprehensive coverage at the most affordable rates, especially when compared with other private health insurance options.

Usually HMO plans are very structured and have specific coverage networks, often housed “under one roof”. But whether they work in the same building or not -all health care requested under the plan will need to be provided only by the HMO network of doctors, hospitals, and specialists.

With an HMO healthcare plan, you are required to make a fixed monthly payment. This premium acts as a kind of pre- payment for medical services. Within some HMO plans and for some services, there might be co-payments required which need to be paid at the time the services are being provided.

Typically, in an HMO your monthly premiums will not increase during the term the policy is in effect.

Most HMO plans function in the same way regarding the delivery of patient care. The differences are based on structure and composition of their service network:

Staff Model

In this type of HMO, there are a number of specialists who are hired and work at an HMO building. Staff model programs tend to be a little bit more restrictive than the other types of HMOs for both patients and doctors because doctors can only treat the HMO members and the insured can only go to these specialists.

Group Model

Also known as closed panel, this type of plan tends to work a little bit differently because the HMO pays a group of physicians to become their network. Patients under that HMO can only use this group of physicians and the group decides how to distribute the money the HMO pays among them.

Open-panel model:

This type of plan allows individual physicians to participate in HMO programs through independent practice associations, that way physicians are able to also treat patients who are not enrolled in HMO programs and are not committed to taking patients just because they are enrolled in an HMO program, providing physicians with a lot more options.

As mentioned before, these plans offer the most comprehensive level of coverage at the most affordable price. Besides this great advantage there are several other benefits to HMOs such as:

• Affordable out-of pocket costs: HMO members are required to make a fixed monthly payment regardless of how much medical care they are going to need, in contrast with other types of health insurance that charge a percentage of each medical service provided to you.
• HMO plans focus on the well-being and preventive care of their insured members. They encourage insured members to practice wellness and preventive medicine. In some cases HMOs offer free health screenings, health educational classes, and discounted health club memberships.
• HMO health plans do not have any limits on lifetime benefit pay-outs, other types of health insurance often do.

Although there are many advantages offered by HMO plans, there are some disadvantages that need to be taken into consideration before deciding to participate in one, such as:

• Limited Network and PCP requirement: these plans tend to be very strict when it comes to specialists you are able to visit. As an individual enrolled in a HMO program you are required to chose a primary care physician (PCP) who is in charge of your general medical care. In case of a medical emergency, or if you feel you need a specialist, your primary care physician must be consulted.

If you are interested in getting services from physicians who are not enrolled in the HMO program, most insurance companies do not cover it. Typically, the HMO plans will not pay for non-emergency care provided by a non-HMO physician. However there are certain types of HMO plans that do allow you to go out of network, for a fee.