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HMO health plans offer fixed monthly fees and co-payments for services within a network of healthcare providers. They are popular for their low costs, but require patients to choose a GP within the network and may limit coverage for certain procedures and medications. Emergency exceptions are allowed, and off-network services and rates should be defined. HMO plans are growing in popularity and are attractive to governments that fund health insurance.
An HMO, or health maintenance organization, health plan is a type of health insurance plan in which customers pay a fixed monthly fee, plus co-payments for services provided by health care providers and businesses. Doctors and other health professionals receive a flat rate per patient from the health insurance company. HMO health plans usually only cover services provided within a network of networked hospitals, doctors, clinics, therapists, and dentists.
HMO health plans are a popular option in the health insurance industry. Many employers and government agencies use HMO plans for health coverage for employees and individuals who qualify for certain types of government-subsidized health insurance, such as Medicare in the United States. In some US states, more than half of all people with health insurance are enrolled in an HMO health plan.
The overall goal of a health maintenance organization is to keep costs low for everyone involved. HMO health plans don’t require deductibles, which can save patients a great deal of money. Fixed fees and co-payments, as well as monthly fees for insurance, are generally the only financial requirements of an HMO. Because of their low costs, healthcare maintenance organizations often provide a large amount of business to the healthcare facilities and businesses they contract with. HMO health plans can be beneficial to patients and caregivers when it comes to cost savings.
There are some requirements of HMO plans, however, that can be controversial and unappealing to patients. HMO clients should choose a GP who is part of the HMO network. This can be problematic if a person has to change doctors or specialists, especially for people with ongoing health conditions. If other health care services are needed, such as a visit to a specialist, the GP must make a referral for the patient in order for the service to be covered by HMO health insurance.
Also, to keep costs down, HMO health plans will often only pay for specific types of procedures, services, and medications. Some patients and doctors therefore find themselves in a position where they have to appeal an HMO’s decisions and ask for additional or increased insurance coverage. This is not uncommon and it is possible that the HMO will agree to cover additional services if deemed medically necessary.
While healthcare organizations are known to only cover services within a healthcare network, some exceptions are allowed in emergency situations. Anyone enrolled in an HMO should have a clear understanding of what is and is not covered and in which situations exceptions are allowed. HMO clients usually receive a book or access to a website listing all covered services, facilities, hospitals, doctors and therapists. Off-network services and rates should also be defined and listed.
Because they are so affordable, HMO health plans continue to be a growing trend in the health insurance industry. They are also very attractive to governments that fund health insurance for some citizens. Health maintenance organizations are popular in several countries, including the United States and Switzerland.
