Insurance Blog

HMO is a common word to every company. Many of us might ask what this three-letter word means. For the benefit of those who are still in confusion, HMO or the Health Maintenance Organizations are companies that take the responsibility in providing insurance for a large group of people, basically an employer group and people who have HMO health insurance obtained from their respective companies.

The insurance provided can be fulfilled to hospitals, doctors, and other practitioners and providers where the HOMO has a contract. With HMO, what is covered are those rendered services by providers who agreed to provide service to patience in accordance with the HMO’s restrictions and guidelines.

Majority of the HMOs require its members to select a primary care physician or PCP who will take charge of the medical services. Generally, PCPs are internists, pediatricians, family doctors, or general practitioners. In case of medical emergency, as long as according to HMO guidelines, patients are required to seek referral from the PCP for her or him to see a specialist or other provider.

HMOs also normally provide preventive care for a cheaper or affordable copayment or even for free to keep their member from developing a preventable condition, thus saving them from a possible great deal of services.

What are normally not covered with HMOs are preventive medical services like immunizations, well-baby checkups, mammograms, or physical exams. Other services that are not covered by HMO include services like outpatient mental health care or any costly form of care, treatment, or diagnosis. Other services that are almost never covered include those services that are not medically required like elective plastic surgery.

HMOs also do the case management to those patients with catastrophic cases identified and to those who have certain chronic diseases including asthma, diabetes, or cancer to make sure that the patient receives the appropriate treatment that he or she needs to prevent the condition from worsening and to make sure that no two service provider provide an overlapping care.

HMO comes in three different models or types, which include the staff model, group model, and the network model.

The staff model has physicians that are paid by and hold office in HMO buildings. Thus, these physicians are direct employees of the HMOs and all contracted to serve only HMO patients.

The group model on the other hand is a type of HMO that does not employ any physicians directly but do have contracts with a multi-specialty physician group practice who are then employing the individual physicians. The contracted group practice can be established by the HMO and will serve HMO patients only. On the other hand, HMOs may also contract with an existing independent group practice and will continue to serve non-HMO patients. This case made the group model HMOs considered to be closed panel for it requires the doctors to be members of the group practice to participate in the HMO. However, physicians may also contact independent practice associations that contracts with the HMO and continue to serve non-HMO patients. This case is an open panel HMO.

The third type is the network model wherein HMO will contract a combination of groups, IPAS, and individual providers.