An Explanation of HMOs

HMOs (Health Maintenance Organizations) remain one of the more affordable options for people in need of health insurance. They are also one of the most restrictive. This makes it troublesome to those who are unfamiliar with HMO practices and regulations.

With any HMO, you choose a primary care doctor. You must see your primary care doctor whenever you need healthcare. This can be a problem during emergencies that are not life threatening. However, if you choose a practice where there are a number of doctors, it usually is easier to see any doctor in the group that is available. For this reason, parents are not hassled when they need to see a doctor for a child with a high fever or sudden ear infection.

If you need to see a specialist for any reason, you must gain approval from your primary care doctor in advance. If you develop a condition requiring you to see a surgeon or specialist, you will first visit your primary care doctor for a diagnosis and then he or she makes an appointment with the specialist and fills out the referral paperwork. If this paperwork is bypassed, the HMO will refuse to pay. In case of emergency, you can talk to your doctor about getting a referral after the fact. If you are taken to the hospital following a car accident or some urgent health reason, you have a few days to talk to your primary care doctor, explain why you did not call his or her office first, and then your doctor will rush the referral paperwork through.

Whenever you see a doctor, you pay a co-payment. Co-payments typically range from $10 to $50 per doctor visit and $100 to $500 for hospital visits. The co-payment is also paid during follow-up care. HMOs make their money by charging you the weekly or monthly premium on top of a co-payment. This co-payment is due with every doctor visit and is usually listed on the front of your insurance card for easy reference.

HMOs generally turn out to be far less expensive than other insurance plans. You receive medical coverage for a lower premium and there is no deductible to deal with in the long run. Other insurance plans often hand out high premiums and then add on a $500 or $1,000 deductible before the health insurance will contribute to health care at all.

Over the years, HMOs have taken a major hit with the public. Many feel that a HMOs first plan of attack is to deny a claim regardless, and then only pay when a member opts to appeal the claim. As a person whose insurance company is an HMO, I have to admit that I spend plenty of time fighting to get payment for claims that never should have been denied. I have had coverage denied because I saw a physician's assistant during an emergency. She happened to be the only doctor in my doctor's office who could see my daughter who was running a fever of 104 and had a weird rash. I have also had claims denied three years after the visit occurred. In each case, I won the battle as soon as I challenged their policy. If you do choose to go with an HMO, the coverage is often excellent, but be prepared to fight for proper coverage periodically.