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Know Your Plan Part 1: Utilizing Your HMO

Employees around the country are adjusting to new health plans as their health benefits continue to evolve. For the next few blogs, we’ll be getting back to basics, discussing some of the health plan types and offering tips on how maximize your benefits under the details of these specific plans. Let’s start with an HMO.

What is an HMO?

An HMO is a type of managed care plan, meaning the health plan has contracted with providers and facilities to create the health plan’s network. An HMO – Health Maintenance Organization – restricts coverage to care received within that network. So for an HMO, you must stay in-network for your discounts and coverage to be applied to your care.

Some Features of an HMO

Networks are a standard trait of health plans. HMOs are unique because of the internal structure of in-network care.

Under HMOs, patients either select or are assigned an in-network Primary Care Physician. This physician, or PCP, coordinates all of the patient’s care. If medical care beyond the PCP is required, the patient needs a referral from the PCP to see a specialist. The patient cannot research and choose an in-network specialist on their own.

Also, there is usually no out-of-network benefit. This means that if a patient sees or visits an out-of-network provider or facility, the charges will be completely out-of-pocket. No coverage is extended; it’s as if the patient does not have insurance. So the patient, is solely responsible for any charges.

Finally, while an HMO is less flexible than other managed care plans, the upside is that monthly premiums are usually lower. These lower premiums are a result of smaller provider networks – patients have fewer options but the health plan can offer more competitive rates for those providers who are in-network.

Tips for Utilizing Your HMO Plan

The best way to maximize your HMO plan is to understand it. Keeps these important points in mind when seeking out medical care and using your health plan:

Get the necessary referrals Seeing a specialist without a referral from your PCP means that you’ll pay for all or most of the care. Avoid this by getting that referral. Call your doctor’s office to request a referral. You might need to schedule an appointment with your primary care physician to discuss the referral and your care.

Confirm specialist is in-network Once your doctor gives you a referral, double check that the specialist is in-network. Contracts with health plans change regularly, so it’s always in your best interest to be sure and avoid the possibility of a surprise.

Check that the specialist is fair priced Even within network, prices for care and providers can vary by 500%. That means that you may end up paying 500% more than necessary. Check ahead and remember that hospitals tend to be more expensive than stand-alone facilities for outpatient services.

Utilizing Your HMO

Have a Question? Leave a Comment!

New to an HMO plan? Or just have a question about how they work? Leave a comment below and we’d be happy to get back to you.

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