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HMOs In General

Summary

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HMO (Health Maintenance Organization) is a generic term for any type of insurance plan or administrative procedure that attempts to direct the patient's treatment.

HMOs started in the mine fields of California as places where medical care, including preventive care, was provided by doctors employed by the HMO in HMO owned facilities. The HMO decided what care would be given. Most HMOs today are virtual HMOs. Care is provided by doctors and facilities that contract with the insurer.

Benefits provided by HMOs are extensive. HMOs have unique features and their own lingo.

Care in an HMO generally starts with a primary care physician who also acts as a gatekeeper to the rest of the system. Primary care physicians generally get paid on a "capitated" basis -- an amount of money per patient no matter how many or few services are provided. Since care is managed, provision of care (including appointments with specialists) generally needs to be pre-approved.  If care is denied, each HMO has an appeals process to follow.

Drugs are provided from a "formulary." There are generally different charges to the member (that's you in HMO lingo) depending on whether the drug is branded or generic.

There are pluses and minuses to HMOs compared to other types of health insurance.

HMOs are generally regulated by the state health department, rather than the insurance department.  In some states, HMOs are regulated jointly with the Department of Insurance. Protection in the form of a disclosure requirement and prohibition against discrimination is generally provided by the federal law known as ERISA. 


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