HEALTH MAINTENANCE ORGANIZATIONS INSURANCES
SPECIFIC DETAILS
HMO insurances are one of the most restrictive insurances in that they require the patient to chose a "Primary Care Physician" who acts as a gate keeper for all of their medical services. The PCP will have to issue a referral for any services that he/she cannot perform in their offices. And precertification must be gotten on all services not performed in a doctors or specialists office before they are done. The patient is also required to only go to hospitals that are within their network in order for the bill to be paid. Emergency services are a little bit more tricky in that the patient is able to receive emergency medical services from a facility not within their network if and only if they had no choice in where they received those services. For instance, when a patient goes out of town and needs emergency medical services then they would naturally seek help at the nearest facility. The patient should call their insurance company within 24 hours of the services and follow-up with their PCP once they get home.
COSTS and COVERAGES
HMO costs to the patient vary by insurance and employer. In most cases the employer will offer the HMO coverage because it less expensive. The patient will be liable for copays associated with each type of service that they receive and they will vary. Co-pays should always be collected at the time of service to prevent in problems with the payment of claims. Some HMOs require that copays be collected at the time of service in their provider contracts. There are exceptions, of course, mainly with emergency services but the patient will almost always owe a copay. Most HMOs do not have annual deductibles nor do they have caps on expenses for the patients.
The coverages of services is restrictive as well. The only services covered by the HMOs are listed specifically within the patient's handbook. ANY other services will almost never be paid and is the full responsbility of the patient. That is to say there are no "out-of-network" benefits.
One thing to note, if the medical facility participates with the HMO as a provider and fails to get the proper referrals and/or precertifications from the HMO medical clearance department the patient will NOT be liable for any rejected services.