HMO insurance is a somewhat restrictive though often less expensive way to get health care. If you have coverage through an HMO (health maintenance organization), your insurance company has its own group of general physicians and specialists, and essentially, your insurance company refers you to doctors.

Whom You Can Visit with HMO Insurance

You will be able to see any medical professional within your HMO network. If you choose to see someone outside the network, you will have to pay for 100 percent of the expense out of your own pocket. Even when you see a primary care physician who is in the HMO network, you need to register the physician with your insurance company beforehand. If you see a medical professional without going through the insurance company first, your claim may be denied. You will also have a referral to a specific hospital in case of an emergency, and you will have to use that hospital for your services if at all possible to avoid having your claim denied.

Coverage and Co-payments

HMO insurance covers everything from routine office visits to expensive surgeries. Routine visits to the same physician will require only one approval. You will have to make a co-payment each time you see the doctor. The amount of your co-payment will depend on your exact policy. How much your HMO reimburses for other services also depends on your policy. Higher-priced policies will typically pay a greater percentage. 

How HMO Insurance Differs from a PPO Insurance Plan

While HMO and PPO insurance plans are similar, they are different in a couple key regards. First, a plan through a PPO, or preferred provider organization, is more flexible. Members of a PPO do not have to have a doctor approved so long as the doctor is in the network. Second, a PPO is usually more expensive because a member pays for the added flexibility. The insurance company cannot negotiate as low of prices with such a wide, flexible group of doctors.

Many people elect an HMO plan despite its restrictions because it is cheaper. HMOs work directly with the individual health organizations in their network to keep prices low. When you see one of the doctors in this network, they will typically charge you less because you are a member of the HMO. Price reduction is possible only with a smaller group of doctors.

Where to Get HMO Insurance

Most health insurance companies will have an HMO option. Many people in the United States have insurance through their employers. Your employer may reimburse you only for a specific type of health insurance. If this is the case, you may have to elect an HMO even if you do not necessarily want to. 

blog comments powered by Disqus