- What is an HMO and how does it work?
An HMO, also called a Health Maintenance Organization, is an organized health care system that provides, or arranges for, full health care services for enrolled members through a network of health care providers. An enrollee must first select a Primary Care Physician (PCP) who then provides or arranges for routine office visits, diagnostic tests, hospital care, surgical care, emergency care and preventive services. If the PCP does not provide the services, the patient must get a referral from the PCP to go to someone else to be treated.
To receive the full benefit coverage, even with a referral from a Primary Care Provider (PCP), a patient must use the doctors, health care providers and health care facilities that have agreed to provide the services for a particular HMO. This group that has agreed to provide these services is called a provider network or provider panel and must be approved by the HMO to offer medical services.
Except in the case of an emergency, services provided outside the HMO network are not covered without a referral from the Primary Care Physician. The referral must also be approved by the HMO before the patient obtains services.
Some HMO's contract with Primary Care Provider (PCP) and pay a fixed fee to the PCP to act as a gatekeeper and coordinate the full range of a patient's medical care. Other HMO's employ their own physicians to treat enrolled members at an HMO clinic.
- If they are all HMOs and they work the same way, why is one more expensive than the rest?
HMOs are not all the same. They may or may not cover the same benefits, their contracts with their provider network may be different, and their administrative dollars are not the same either. In addition, the number and type of people, or “Covered Lives” enrolled with HMOs can be different because some HMOs may have very healthy persons while others have very sick people. As a result, expenses may be higher for HMO's that have sicker covered individuals.
- Can I go to any doctor and/or hospital I want I want if I have an HMO?
To receive the full benefit coverage under an HMO, a patient must use doctors, health care providers and health care facilities that have agreed to provide the services for a particular HMO. This group that has agreed to provide these services is called a provider network or provider panel and must be approved by the HMO to offer medical services.
Don't forget to contact your Primary Care Provider (PCP) for a referral form before you go for any appointment for any other treatment.
Except in the case of an emergency, medical services that you go for that are outside the HMO network are not covered without a referral from your Primary Care Physician. The referral must also be approved by the HMO before you obtain services.
- The physician I want to see is not in my network, what must I do?
To receive the full benefit coverage under an HMO, a patient must use the doctors, health care providers and health care facilities that have agreed to provide the services for a particular HMO. This group that has agreed to provide these services is called a provider network or provider panel and must be approved by the HMO to offer medical services.
There must be a valid reason for your PCP to send you outside the network to get treatment. You can call the Member Services Department of your insurance company to discuss alternatives. So, unless you are willing to pay for the services yourself, be sure you have spoken to your HMO Member Services Department.
Except in the case of an emergency, medical services outside the HMO network are not covered without a referral from your Primary Care Physician. The referral must also be approved by the HMO before you obtain services.
- Can I change PCP whenever I choose?
You have the opportunity to change Primary Care Providers at certain times during the year. Consult your Member Services Handbook or contact your employer to find out the deadlines for you to switch to a new doctor. It will take time for a transfer to become effective, so please remember to allow enough time before you make an appointment with your new doctor.
- Where do I get a list of providers in my area?
When you enroll in an HMO, you will receive a booklet with the names, addresses, phone numbers, and other identification information for all of the providers who have contracted with your HMO to provide services in the coming year. There are sometimes additions and corrections to this list, so you may want to check with the Member Services Department of your HMO if you don't see your first choice of a provider in the book.
Your employer keeps updated copies of all provider lists and the Member Services Department of your HMO can also assist you if you still have questions.
- Who do I notify when I change my PCP?
There will be specific instructions and an official form that you will have to complete so check your Member Handbook, call your employer or contact the Member Services Department of your insurance company if you have any questions.
Doctors cannot transfer a patient's records without a written request so you may have to sign a records release to get your records moved to another office.
- Do I need to obtain a referral?
The need for a referral depends on the type of service and on your employer's group plan. If you are in an HMO, it is possible you will need to see your Primary Care Provider before going to specialist.
Your coverage may include a limited number of visits to a certain kind of provider. You should always confirm your benefits before seeking treatment to avoid higher out-of-pocket expenses. Check your Member Handbook, ask your employer or contact the Member Services Department of your Plan to help you.
An insurance company can offer many different kinds of coverage under many different kinds of plans. So, even if you and someone else you know deal with the same insurance company, the kinds of benefit for each of you can be very different. Do not expect that the provider will know what your plan will cover.
- Can I go to the chiropractor or do I need a referral from my doctor?
The need for a referral depends on your employer's group plan. If you are in an HMO, it is possible you will need to see your Primary Care Provider before going to any specialist, including a chiropractor.
Your coverage may include a limited number of visits to a chiropractor. You should always confirm your benefits before seeking treatment to avoid higher out-of-pocket expenses. There Your Member Handbook, your employer or the Member Services Department of your Plan can answer this for you.
An insurance company can offer many different kinds of coverage under many different kinds of plans. So, even if you and someone else you know deal with the same insurance company, the kinds of chiropractic benefit for each of you can be very different. Do not expect that the provider will know what your chiropractic coverage is.
- What about coverage for a child attending an out-of-state school if I have an HMO?
Coverage for your child attending an out-of-state school is determined by your individual employer's benefit plan. Variables for this coverage may include the age of your child, as well as other factors. Consult your Member Handbook, contact your employer, or call the Member Services Department of your plan.
- What happens if I am traveling and I have an HMO?
To avoid unwanted surprises, always confirm your insurance coverage BEFORE you travel out of the area since your coverage while traveling is determined by your employer's benefit plan. The extent of time you will be away from home or work and the availability of network or contracted healthcare providers are just two of the many factors that can affect your benefits. In addition, co-payments and co-insurance will apply when you seek care out of the area.
To get the maximum benefit allowed under your plan, you should let your insurance company know if you receive treatment in an emergency room while you are traveling.
There is a Primary Care Physician or a qualified medical professional who covers a medical practice and who is available 24 hours a day. Verify coverage information before you leave your home area.
It is always frightening to have a health problem when you are not in familiar surroundings, but not every illness is an emergency.
An emergency is the sudden onset of severe or painful symptoms that require immediate medical attention because they would place a patient in serious jeopardy.
In the event of a life-threatening emergency, patients should go to the nearest emergency room for treatment. Prior authorization from an insurance company is not required, but patients in managed care should notify their primary care provider or the Insurance Plan within 24 hours, or as soon as is reasonably possible, so that appropriate, coordinated care can be arranged. Emergency care is not the same as urgent care. (See below for a definition of urgent care)
Urgent Care is needed to minimize the severity of and complications from an unexpected illness or injury that is not an emergency or life-threatening. Urgent care is not the same as emergency care. (See above for a definition of emergency care)
Most Insurance Plans, but not all, cover emergency services while you are traveling. Some Plans require a co-payment for emergency room care and will put that financial information on your insurance card. It is recommended that you notify your insurance company if you receive treatment in an emergency room setting.
In states with a Prudent Layperson Law, an insurer must pay for an emergency room visit if a prudent, sensible, layperson, who is acting reasonably, would think that an emergency medical condition existed. However, it is important to know that some Insurance Plans will not cover an emergency room visit if the symptoms appeared more than 24 hours earlier.
