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Health Maintenance Organization Plans

A Health Maintenance Organization (HMO) is a managed care organization whose members are entitled to receiving health care services from participating doctors, hospitals, and clinics. An HMO lays emphasis on preventive medicine. In a departure from usual indemnity insurance, health care provided in an HMO follows a set of guidelines provided through the HMO's network of providers. In this case, providers contract with an HMO to welcome more patients and in return provide services at reduced prices. This pact results in a lower monthly premium, which is an advantage over indemnity insurance, if its members abide by the additional restrictions. Different HMOs offer different health care services; so it is important to compare available plans. There are a few services, such as outpatient mental health care, that are often only covered on a limited basis.

In an HMO, you are required to choose a primary care physician (PCP) from its network of physicians and facilities. Your PCP will then be responsible for your health care and also for making referrals to specialists and approving any further medical treatment that will be deemed necessary. If there is an emergency or medical compulsion, one may be allowed to choose doctors outside of the list.

In general, you will be required to make a co-payment for the health care services offered. There are, however, some health insurance plans and services that do not charge any money. Under any HMO policy, no treatment received outside of the network that is not pre-approved by your primary caregiver will be covered.

An HMO plan is favored by many as they do not need claim forms for office visits or hospital stays. Instead, all they need is to present a card, like a credit card, at the doctor's office or hospital. However, you should prepare yourself to wait longer for a doctor's appointment than you would with an indemnity insurance plan in non-emergency situations. As HMOs charge a fixed fee for your health care, they try to ensure that you receive basic health care for your medical problems before they turn grave. In spite of paying a small co-payment for each office visit, your total health care costs will perhaps be lower in an HMO than with fee-for-service insurance.

However, as it is mandatory to obtain a referral from your PCP, it sometimes becomes complicated to receive specialized care under an HMO plan. No health care cost from other providers is covered or covered just nominally except in cases of emergencies.

As an HMO does have more control over your health care than other managed care plans, the cost is also more controlled. In addition to the monthly health insurance premium, you pay very few other fees if you use the HMO's network. For health care services covered under the plan, HMOs will ask you to make minimal co-payments for services rendered. You must, however, bear the entire burden of non-network care.

In order to choose the right HMO, try to know the following things: the number of doctors you can choose from, whether the network comprises private or group practice physicians, doctors who are accepting new patients, if you can change your PCP, the procedure for referrals to specialists, arrangements for handling emergency care, health care services offered, location of hospitals within the network, yearly total for monthly premiums, if there are any co-payments and so on.



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