Health coverage can be a very complicated topic to research and understand, but having a plan that’s right for you and your family is necessary for your peace of mind, not to mention your health. If you’re on a very limited budget, one of the plans you might want to consider is an HMO, which stands for health maintenance organization. In the United States, an HMO is a kind of a managed care organization where the doctors, hospitals, labs and other health care providers you see are under special contract and part of the HMO network.
Through an HMO, members choose a primary care physician (PCP) from the network to act as the director, or “gatekeeper”, for access to medical services. A PCP is usually a family doctor, general practitioner, internist or pediatrician. Unless there is a medical emergency, member patients require a referral from the PCP to see a specialist or other doctor, also within the network, and these referrals must be within the HMO’s guidelines of services and restrictions. HMOs may provide preventive care for low or no cost so that members don’t develop preventable conditions that would require expensive or continuous medical services. More costly forms of care may not be covered. Any treatment that is not medically necessary, such as elective plastic surgery, is almost never covered by an HMO.
In cases where member patients with catastrophic medical conditions or patients with chronic diseases like cancer, asthma or diabetes have been identified, the HMO will take a greater role in overseeing the patient’s care by assigning a case manager. This case manager makes sure that health care professionals do not provide overlapping care and that the member patient is receiving the right kind of treatment as well as keep the condition from worsening.
HMOs are regulated at both federal and state levels. Because of their restrictive appearance, HMOs have often received bad press and been the target of many lawsuits alleging that the HMO restrictions prevented necessary care to member patients. Because an HMO does not control the medical aspect of providing care, only the financial aspect, it is often shielded from malpractice lawsuits. The HMO’s screening process is a factor in determining if the HMO can be held responsible for a physician’s negligence.
HMOs today operate in many different forms and can have multiple divisions that operate under a different model or even a blend of models. Salaried physicians who have offices in HMO buildings work under the staff model. They are direct employees of the HMO. If an HMO contracts with a multi-specialty physician group practice rather than employ physicians directly, this is known as the group model. The individual physician doesn’t work for the HMO but for the group practice. In the network model, an HMO might contract with a combination of individual physicians and physician groups. Most HMOs with other lines of managed care businesses, such as PPOs and POS, now use the network model.
