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What is an HMO?

October 28, 2010

Question: What is an HMO?

Answer: An health maintenance organization (HMO) is a managed group health insurance plan that provides health care services to plan participants through a broad system of participating health care professionals and facilities. The HMO emphasizes preventive health care, including periodic physical exams and encouragement of a healthier lifestyle.

Your primary care physician is the cornerstone of care

HMO patient service generally revolves around a primary care physician (PCP). The PCP is the primary health care contact person who oversees your care. As an HMO plan participant, you have the freedom to choose any PCP that belongs to the HMO network.

In the event that you need to see a more specialized provider (such as a cardiologist or oncologist), your PCP must provide you with a referral to a specialist within the network in order for the expense to be covered by the HMO. Care received from an out-of-network provider may be covered at a considerably lower dollar level, but in many cases is not covered by the HMO at all--check with your plan to be sure.

Co-payments and other expenses

HMO-insured individuals are often required to pay a relatively small co-payment ("copay") at the time of each visit and/or for each prescription. The amount of the copay is a pre-specified, flat fee, unconnected to the actual cost for the health care service received.

Remember, non-emergency care must generally be received through the HMO network of providers in order for the claim to be paid.

Bethany Harris

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