Health Maintenance Organization insurance plan or HMO health insurance plan is a type of managed care organization that provides health care system to support both financial and medical treatments of their members. It operates by setting out guidelines from which their network of affiliated doctors can base their treatments and other medical needs.
HMOs have generally lower monthly fees compared to other insurance system that is usually deducted from a paycheck. It requires co-pay or the amount paid during treatment that is deductible from the total medical cost. This payment, however, may vary depending on each medical office's rate, prescriptions and the medical treatment used.
Basically there are two reasons by which HMO can provide less expensive health care. First, HMO deals with quantity of patients and with direct health insurance providers. With this, a great deal of negotiation is possible to provide patients with reasonably priced health care. Second, by removing treatments which are deemed unnecessary by HMO while focusing on preventive health care done through distribution of informative handbooks and health guides.
Choosing a primary care physician or PCP is compulsory to being an HMO member. PCPs are usually general practitioners, internists, family doctors or pediatricians who act as 'gatekeeper' for medical services. They determine what treatment the patient need or does not need and also the one responsible for taking care of all health-related concerns unless there is a need for a specialist. Members though cannot go directly to a specialist without a referral from PCP. If PCPs can still manage the patient's concern, patients are not given referral yet; except of course for emergency and OB/GYN cases. There is, however, a health maintenance organization which does not require referral by PCP before going to a specialist called an open access HMO. It entails higher cost sharing expenses like coinsurance and co-payment than the regular HMO.
Although HMO is popular for providing affordable health care, there are however many issues regarding the quality of service it provides. Members complain that physicians are usually second rate for they do not enforce suitable tests when evaluating their patients. Some HMOs even refuse to pay treatments and tests even with their PCP's advice. In most cases, physicians tend to spend less time with each patient as HMO physicians are compelled to see a large number of patients on a limited time.
Since HMOs limit their service to a specific network of physicians and hospital, this means that out-of-network consultations are not covered. Whenever you decide to consult your preferred physician, you have to shoulder the entire cost of all medical procedures. Patients cannot demand treatment rather just accept whatever is given by the physician. HMOs require PCPs to rationalize the treatment needed on the patient based on the policy coverage by the HMO.
The benefits of buying a HMO health insurance plan is still on debate. Critics say that with the conditions placed by HMO, medical practitioners are encouraged not to give referral to patients when possible. HMOs however stressed out that the service of low-priced health care is better than not having any health care plan at all.
Get completely informed about gettin a HMO health insurance plan, PPO health plans, and other low cost individual health insurance plans before chosing the correct health care for yourself and your family. We provide in-depth information regarding all of the above topics at Tennessee Individual Health Insurance.
