Frequently Asked Questions

 

What is an HMO? An HMO is a Health Maintenance Organization, which is a network of health care providers including doctors, hospitals, pharmacies, and other medical facilities and professionals. The network works together to manage the quality and cost of each member’s health care.

How does an HMO work? Each HMO member selects a Primary Care Provider (PCP) from a directory of participating physicians in general practice, family practice, internal medicine ,or pediatrics. The PCP will coordinate all of the member’s health care needs. If the PCP can effectively provide care, the PCP will. If the PCP determines a specialist is needed, the PCP will refer the member to a participating specialist in the HMO network.

What are the advantages of an HMO? HMOs are designed to manage the costs of medical care, which means members enjoy lower out-of-pocket expenses compared to traditional medical insurance. Visits to the doctor’s office, hospital charges, and many other medical care expenses are covered at 100% after a small co-payment such as $5 or $10 per visit. Generally, prescription medicines, routine physicals, lab tests, vision exams, well-baby care, and maternity visits are covered. HMO plans do not require you to pay an annual deductible before services are covered, and usually have no lifetime maximums. HMO providers conveniently take care of most paperwork, so members do not have to complete claims forms.

Are there any drawbacks to an HMO? Some people who are accustomed to selecting their own health care providers and facilities find working with a Primary Care Provider system to be inconvenient or restrictive at first. However, HMO members who recognize the cost-savings, quality care, and conveniences they enjoy with managed care are generally satisfied with the trade-off. No benefits are paid if a member decides to go to a health care provider that is not in the network.