HMO
What is a Health
Maintenance Organization (HMO) and how is it different from other
kinds of health plans?
A HMO is a health plan that typically incorporates the concept referred to as Primary Care Physician (PCP) or Gatekeeper. Most HMO plans require participants to select a PCP. The PCP in return becomes responsible for the coordination of the participants medical care. Included in the PCP/Gatekeeper concept is a requirement that PCPs refer participants to specialists within the same network of physicians (and in many instances the same medical group) as the PCP. Most HMOs do not provide benefits for non-emergency services rendered by physicians and facilities that are not in the HMOs approved network.
Typically, HMOs emphasize preventive medical care and, in an effort to encourage participants to take a preventive approach to their individual health, provide a high level of benefit for these services. Unlike other types of health plans, HMOs typically do not require participants to meet annual deductibles or pay a percentage of the cost of their care. Out-of-pocket expenses for most HMO participants are limited to low-cost encounter fees often referred to as copayments.
Many HMO participants do not realize that most insurance carriers have empowered medical groups with the responsibility for approving or authorizing the procedures and overall level of care recommended by their member doctors. This creates a scenario in which insurance carriers are unaware of a medical group’s decisions regarding the care of participants. Under a typical HMO, if a participant is denied care, the insurance carrier has no knowledge of that decision unless directly notified by the attending physician or the patient. HMO participants are most successful and report higher levels of satisfaction with their medical plan when they build a strong relationship with their PCP, understand how their particular HMO plan works, and learn to be their own advocate.
Can I change my PCP?
Although each insurance carrier has its own guidelines governing PCP election…Yes, most HMOs allow participants to change PCPs. In fact, most HMO plans allow participants to change PCP elections as often as monthly.
How do I find out if my doctor is a PCP?
There are several ways to determine if your doctor is a PCP under your health plan. The best way is to consult the insurance carrier’s online provider directory. Provider directories can be found at most insurance carriers’ home website addresses. The PCP provider directory found there is the most current reliable information. Website links to many insurance carriers can be found in the links section of this website. You may also contact your doctor’s office or your insurance carrier’s Member Services department.
I keep hearing about "Managed Care". What is it and how does it impact my medical plan?
One thing most medical plans have in common is "Managed Care". This includes not only HMOs, but most EPO, POS, PPO and Indemnity plans too. The term managed care refers to cost containment features imposed by insurance carriers, by a medical group, or by a State or Federal legislative body. Most plan participants encounter managed care in the form of:
pre-authorization requirements imposed on surgical and other services;
limits on the number of visits available for certain services such as physical therapy, out-patient counseling and chiropractic;
limits on the dollar amounts an insurance carrier will pay for certain services;
penalties for the inappropriate use of an emergency room and other emergency service;
the use of Primary Care Physicians (PCP)/Gatekeepers; and/or
capitation.
Managed care features are specific to a plan and insurance carrier so you may encounter other forms of managed care. The impact of managed care on you will be specific to your plan and personal circumstances.
What is capitation?
When you choose a PCP, you are also choosing a medical group. Capitation is a cost containment feature that provides financial compensation to the medical group with whom your PCP is affiliated. Under a typical capitation arrangement, a medical group receives a monthly payment from an insurance carrier for every patient registered with an affiliated PCP. These payments are placed in a pool of funds from which your PCP receives payment for the services rendered to you. Your PCP is compensated by their medical group, not the insurance carrier. Typically, the medical group is empowered with the responsibility for approving and authorizing the care you receive.
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