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What is HMO Health Care?

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  • Written By: Harriette Halepis
  • Edited By: Lindsay D.
  • Last Modified Date: 05 November 2016
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HMO health care is a common type of health care that is offered throughout the United States. Directly related to a Managed Care Organization (MC), HMO health care is generally supplied by companies with more than 25 employees. HMOs differ from other health care plans due to the fact that all doctors and specialists seen by an HMO patient must agree to specific terms set forth by the HMO.

There are various forms of HMO health care plans in operation. Staff models, group models, and network models are all part of the larger HMO health care category, yet the specifics of each plan differ drastically. Staff models include physicians that work exclusively with an HMO provider. Group model HMO plans are not directly linked to individual physicians, but they are linked to a team of specialized HMO physicians. Network models allow HMO patients to contact any group, individual medical professional, or IPA (Independent Practice Association).

Almost all HMO members are required to select one primary care physician (PCP). These individuals usually consist of interns, general practitioners, pediatricians, or family doctors that act as a main source for all medical referrals. In order for an HMO patient to seek specialized medical attention, they must first consult with their chosen PCP.

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In turn, this selected individual will then refer a patient to a specialist according to specific HMO guidelines. Some HMOs also offer a form of preventative care in lieu of specialized care with the goal of preventing a serious illness from occurring. A PCP does not need to be contacted if the HMO patient is in instant need of emergency medical attention.

Many HMO health care providers also conduct regular utilization reviews. These reviews exist to ensure that all primary care physicians are constantly and consistently abiding by HMO guidelines. This system ensures that all primary care physicians are performing the same services and tasks when it comes to HMO patients.

HMO patients that have a serious illness, such as diabetes, cancer, or asthma, may be assigned a specific case manager. In this instance, a case manager will monitor an individual in order to ensure that a specific medical condition does not worsen. Case managers also check with all medical professionals associated with an HMO patient.

HMO health care laws and plans can vary from state to state. Some states have strict guidelines that all HMOs must follow, while other states do not attempt to regulate HMO plans in any manner.

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sunnySkys
Post 7

@Azuza - Having a different kind of plan sometimes won't allow you to see specialists any sooner. I have a PPO plan, so I don't need a referral to see a specialist.

I needed a specialist for something, and all the ones my insurance covered were booked for months. Yeah, I guess it would have been a pain to go through the extra layer of getting a referral from my regular doctor, but I don't think it would have made too much difference in the end.

Azuza
Post 6

I think an HMO plan is pretty much the worst insurance plan there is. I mean, it does cost less, but that's the only advantage.

A lot of HMOs have very few doctors that are in network. A good friend of mine has an HMO and she was having some issues with depression. She had a really hard time convincing her primary care doctor that she needed to see a psychiatrist. He kept telling her she was "tired."

She was also so depressed she didn't really want to put the effort in to get help. Finally her husband want to the doctor with her and raised a stink to get her her referral.

When she finally did get her referral, the only psychiatrist in her network that was within driving distance was booked for months! Totally ridiculous!

SarahSon
Post 5

I remember having some HMO medical coverage when they were first introduced. The plans and policies have gone through several changes since those early years.

I always wondered how long they would be able to operate because they were so cheap. The plan that I was covered under when I got pregnant with my first child was very good.

I only paid $5.00 for everything. That included all of my office visits, hospital and doctors fees when I had a cesarean section and had to stay in the hospital for a week.

We were young and poor and I am very thankful that we had that coverage. We have different medical coverage today, but I think you would have to pay more than that today even with a good HMO plan.

dfoster85
Post 4

The nice thing about HMO coverage is that as long as you stay in-network, it's generally pretty comprehensive. You don't have to worry about a lot of copays and coinsurance and so on.

But the in-network thing can be pretty limiting. And having your primary care provider be the gatekeeper for specialists can sometimes be a problem. With an HMO, sometimes you have no right to a second opinion. I have a coworkers whose sister had an HMO and her primary care doctor insisted for several months that her stomach problems were caused by "a virus."

He wouldn't let her see a specialist. Finally, he decided she had an ulcer and she was scheduled for surgery. It wasn't

an ulcer. It was esophageal cancer. They sewed her up without doing anything and told her she had a few weeks to live.

Seeing a specialist sooner would not have changed the outcome. Her cancer was too serious. But it could have spared her some stress and would have given her family more time to say goodbye. The problem wasn't so much that she had an HMO as that she had a lousy primary care provider. That person has a lot of power in an HMO, so you'd better choose wisely!

suntan12
Post 3

@SurfNTurf- My doctor was not in the network so I had to wait until the following year to elect to receive PPO health coverage because this allowed me to see the doctor that I wanted. The main difference with a HMO vs. a PPO is that with a PPO you do pay higher premiums but you also get to pick the doctor that you want and unlike with an HMO where you have to have a referral from your primary care doctor in order to see a specialist, with a PPO you can see any specialist whenever you want whenever you want.

The only caveat with a PPO is that if the doctor is out of the network you

can still see him, but you will have to pay the out of network charges which is usually about 25% of the bill. This is what I had to do when I had my son, because my obstetrician was out of the network, but there was no way I was going to switch doctors after this doctor already had delivered my daughter and I was very comfortable with him.
surfNturf
Post 2

A few years ago I used to have HMO health coverage. The advantage to a plan like this is the cost savings because it is the least expensive plan to consider when buying health insurance, but the problem is that along with the cost savings you are also limited in terms of the doctors that you can see.

With HOM healthcare, you have to select a doctor that is in the network to function as your primary doctor, but what happens if you don’t want a doctor that is in the network?

You either see a different doctor that does not know your history or pay out of pocket which makes the insurance useless. If your doctor is in the network then this insurance coverage can be great if not, you might not be happy with it because there are a lot of rules and regulations with respect to HMO's.

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