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What is a HMO?

QuestionWhat is a HMO?

AnswerHMO stands for Health Maintenance Organization. HMO is an insurance company that offers health plans, that provides medical care from an approved network of doctors, hospitals, pharmacies, laboratories, and other care givers. The patient needs to pay a preset minimum fee per visit. The HMO fees are usually lower than PPO or Preferred Provider Organizations charges.

The advantages of HMO are:

  • No or very low deductibles
  • Comprehensive benefits
  • Preventive care is often good

The disadvantages of HMO are:

  • HMO plan includes only a particular chain of hospitals and doctors
  • The patient must see doctors within the network
  • The patient must get permission from the primary physician to see a specialist, or the HMO may not pay for the services
  • HMO’s often refuse to pay for the emergency visits, if they don’t consider it as a true emergency

Important points regarding HMO plans is that once you have signed up for coverage and received your HMO plan, be sure to read your policy thoroughly and carefully. You should know answers to questions like:

  1. Which doctors, hospitals you may see?
  2. What procedures are covered and what aren’t?How are emergency visits handled? And what procedure you must follow to get the full coverage?
  3. How are emergency visits handled? And what procedure you must follow to get the full coverage?
  4. What kind of cases come under emergencies? (As they may deny coverage, if they don’t consider your problem as an emergency.)
  5. What is the co-payment cost? (i.e. How much you will have to pay per visit?)
  6. Find out the procedure for claims, if any.