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Health Insurance: HMOs (Managed Care Policies)

How Does An HMO Work As A Practical Matter, From A Member's Point Of View?

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Some HMOs provide care in their own facilities with employee health care providers.

Most HMOs provide care through setting up guidelines of health maintenance and care through contracts with health care providers and health facilities. Patients can only go to the doctors who have contracted with the HMO. Those doctors agree to follow the plan's guidelines of medical care for a set schedule of fees. Benefits Under An HMO,discusses the plan design more specifically.

Upon enrolling in an HMO, you choose a Primary Care Physician (PCP) from the insurer's Directory of Participating Providers. Most HMOs have put the list of their Participating Providers on line. (For information see: How To Choose A Primary Care Physician).

You pay your co-pay at the doctor's office at the time of service. If you need tests or x-rays, your PCP will perform them in his or her office or advise you where to go.

If you need to see a specialist, what happens depends on whether your plan insists that you get prior approval before seeing a specialist, or allows you to make an appointment without prior approval.

If prior approval is required, your PCP will request it for you. If your HMO requires prior approval to see a specialist, ask the PCP to get you an unlimited pass to see a specialist, or at least a multiple number of times.

Generally, your PCP will suggest the name of the specialist for you to see. However, you probably have a choice of specialists within the HMO. For help in choosing a specialist, see How To Choose A Specialist.

You or your PCP will call for the appointment. If your doctor's office calls, you are likely to get an appointment sooner than if you call yourself.

When you see the specialist, there will be a co-pay to pay, just like there was when you visited your PCP. Follow-up visits with a specialist are only covered if they were part of the referral, or if a new referral has been approved, or if no prior approval is required by your insurer.

Any additional treatment you may require must be approved by the HMO.

If you receive a prescription for a medicine, it must be taken to a pharmacy that contracts with the HMO. Such pharmacies are also listed in the Directory of Participating Providers. You pay a co-pay when you pick-up your prescriptions. The amount of the co-pay likely differs depending on the type of drug which was prescribed (for instance, brand name vs. generic.)

Variations on the HMO model are developing as HMOs respond to members' needs and as HMOs obtain experience with the model. Some current variations are:

  • To permit women to have an OB/GYN as their PCP.
  • To allow the PCP to make a specialist referral without approval of the HMO or a referral committee.
  • To allow a PCP to refer to specialists for multiple visits, or an unlimited number of visits.
  • To allow self-referrals to specialists by members rather than insisting on referrals by PCPs.

Keep in mind that HMO benefits usually include regular checkups for you and your covered family members. Many HMOs allow women to visit a network gynecologist annually without the primary doctor's referral. Maternity care is usually fully covered.

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