High Maintenance Organization (HMO) plans are for individuals who seek health insurance offered coverage through a network of physicians. With an HMO plan, you will likely have coverage for a wider range of healthcare services than you would through another type of plan. HMO insurance refers to the types of insurance plans that allow you to visit a select network of doctors and specialists who work with your insurance provider. Generally, there are no exceptions to this rule unless in a case of a medical emergency. HMO plans typically offer lower out-of-pocket healthcare expenses. You may not be required to pay a deductible before coverage starts and your co-payments will likely be minimal. With an HMO plan, you are required to choose a primary care physician (PCP) who will take care of most of your medical needs. If you need to see a specialist, you are required to have a referral from your primary care physician.
Features Of HMO Plans
HMO plans provide health insurance coverage for a monthly or annual fee. They limit member coverage to medical care provided through a network of doctors and other healthcare providers who are under contract with the HMO. An HMO is an organized public or private entity that provides basic and supplemental health services to its subscribers. The organization secures its network of health providers by entering into contracts with PCPs, clinical facilities, and specialists. The medical entities that enter into contracts with the HMO are paid an agreed-upon fee to offer a range of services to the HMO’s subscribers.
With HMO plans, it is important to ask for medical care within your provider’s network of doctors in order to keep your out-of-pocket expenses low. Your selected PCP can refer you to specialists who are within your plan’s network to ensure you stay covered under your plan. Seeking health services outside of an HMO’s network may result in paying the full bill out-of-pocket for the benefits and services you receive, with the exception of a medical emergency.
Primary Care Physician (PCP)
The beneficiary is required to choose a Primary Care Physician (PCP) from the network of local healthcare providers under an HMO plan. A PCP is typically the beneficiary’s first point of contact for all health-related issues. This means that an insured person cannot see a specialist without a referral from their PCP. Specialists to whom the beneficiary is referred are within the HMO coverage, so their services are covered under the HMO plan after copayments are made. If a PCP leaves the network, subscribers are notified and are required to choose another PCP from within the HMO plan.
The average HMO plan can have a premium from $18 per month (the average annual premium is somewhere around $216). This is less costly than any other healthcare plan. When you do receive care from an in-network provider, you may be responsible for a copayment each time you receive care. In addition to low premiums, there are typically low or no deductibles with an HMO. Instead, the organization charges a copayment for each medical service. Copayments in HMOs are typically low – usually, $5, $10, or $20 per service.
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