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What are the Different HMO Benefits?

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  • Written By: Ken Black
  • Edited By: Andrew Jones
  • Last Modified Date: 17 November 2016
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    Conjecture Corporation
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There are a number of benefits a health maintenance organization (HMO) will provide to those who subscribe to the plan. HMO benefits cover a variety of health care situations, including preventative care, therapeutic care, and long-term care in some cases. The HMO plan also gives access to a primary care physician and specialists as needed. HMO benefits, while the subject of many complaints, are also responsible for helping many people to stay healthy.

The main HMO benefits relate to payment for health services received. These may be services to treat a health problem, or may be preventative services, such as annual checkups, or even a gym membership. HMOs will pay a good portion of the services received in most instances, as long as some simple rules are followed, including going to doctors participating in the health insurance plan, and getting pre-approval when necessary.

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Visiting the doctor is one of the most popular HMO benefits. The family physician, pediatrician, or internist will serve as the primary care physician for the patient, or person covered under the policy. Doctor visits are usually a separate part of the policy, not subject to the deductible requirement. Therefore, those who want to visit a doctor will be able to do so and submit a claim to the HMO without having to worry about the deductible. Only a small co-pay will usually be required. Most HMOs do not require prior approval to see a primary care physician if there is some sort of a concern about health.

For major medical problems, HMO benefits become very important. Hospitalization is not cheap. Though the deductible will usually apply to major hospitalization, the overall benefit to the patient is still significant. Once the deductible is met, the HMO will usually pay as much as 80 to 90 percent of the bill. Some premium plans will even cover the bill fully. For those who are experiencing a very costly illness, there is also an out-of-pocket maximum built into most medical plans. This will limit the financial loss an individual may suffer from a health-related issue to a certain amount per year.

HMO benefits may also apply to prescription drugs, which can be a very important part of a health plan. In some cases, the drugs needed by individuals may be free. In other cases, they may be discounted, with the HMO paying the difference. This can be a very significant benefit for those who have chronic illnesses, and who need medications regularly. Some would end up spending hundreds, if not thousands, of dollars each month on prescriptions.

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