What is a Health Maintenance Organization (HMO) and how
does it work?
A
Health Maintenance Organization (HMO) provides health care
services to enrolled members through a panel of HMO providers.
When you enroll in an HMO, you select a participating PCP
for each enrolled family member. You may select any participating
PCP from your HMO's provider directory. Your PCP coordinates
your medical care, either by providing that care or by issuing
a referral to another provider. With an HMO plan, you generally
pay a fixed amount each time you receive care. Coinsurance
typically does not apply with an HMO.
Except in an emergency as defined by the plan, or with previous
approval through the plan's authorization procedures, only
services provided by or referred by your PCP will be covered
under an HMO.
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What is a primary care physician (PCP)?
With
some HMOs, you are asked to select a primary care physician
(PCP) to be the personal doctor for each enrolled family
member. If you are asked to select a PCP, you may select
any participating PCP from your HMO's provider directory.
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What are the advantages of an HMO plan?
| There
are several advantages when you belong to an HMO. Generally: |
| • |
You
don't need to submit claim forms and wait to be reimbursed
by your plan. |
| • |
Your
HMO provider obtains any needed precertification for
you. |
| • |
In
most cases, you only pay a copayment (fixed dollar amount)
at the time you receive covered services. After you
pay your copayment, you owe no more payments for the
covered services. |
| • |
HMO
plans typically cover certain preventive care services |
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How
does an HMO work when I obtain care outside the HMO?
Generally,
HMO plans do not cover services provided outside the HMO
except in certain emergency situations.
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My plan requires me to select a PCP when I enroll. How do
I do so?
When
you enroll, you may select any PCP (primary care physician)
from your HMO's network provider directory for each covered
family member. Your enrollment materials will request your
PCP's name, or a code for that PCP from the network provider
directory. You will generally find PCPs in the areas of
family practice, general practice, internal medicine, or
pediatrics. Some plans allow a woman to name one PCP for
her primary care and a second specialist in Obstetrics and
Gynecology for services such as pelvic exams and Pap smears.
It's a good idea to check with your HMO before you select
a PCP. Some PCPs have "full" practices and cannot
accept new patients, and others may no longer be participating
in the network.
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Can I change my PCP?
Yes.
You or a covered family member may change PCPs for any reason.
Just call the member services number on your ID card.
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Do I ever need to file a claim form with an HMO?
You
generally don't need to file a claim form when you see your
PCP. Just show your ID card when you receive services so
the office knows to charge you a co-payment and bill your
HMO plan for the balance. The plan works the same way when
your PCP refers you to another HMO doctor or hospital for
care. Just show your ID card and pay your co-payment.
In a true emergency, your eligible expenses may be covered
even if you had to go outside the HMO as long as you follow
the HMO plan's rules. In this case, the provider will bill
you directly. You then need to submit a claim form to be
reimbursed. You will be reimbursed for part of the bill.
To file a claim, follow the instructions on the claim form.
If you received an Explanation of Benefits (EOB) statement
from another health care company, be sure to include a copy
with your claim form.
.
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What happens if I need specialty care that is not
available from my HMO?
You
may be referred to a non-HMO provider if you need specialized
care that your HMO determines to be medically necessary
and the care is not available through the HMO in your area.
As long as you use the provider you're referred to by your
HMO and follow your HMOs rules, you'll be covered for that
care.
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What happens in an emergency?
In a true emergency, get the care you need
as quickly as you can. Assuming you are able, try to contact
your HMO, even in an emergency. However, even if you are
unable to contact your HMO, get the care you need. Even
if you need to seek care from a non-HMO provider, your plan
will cover emergency care as long as you follow the plan
rules.
Check to see how your plan defines a true emergency. Examples
typically include severe bleeding, chest pain and unconsciousness.
Also check to see how soon after the onset of the emergency
you must notify your HMO in order to be covered.
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What
happens if I need care while I'm traveling?
If
it's not an emergency and you need care while traveling,
call your HMO and your HMO can help you arrange a referral.
In a true emergency, get the care you need as quickly as
you can. If you are able, contact your HMO, even in an emergency.
However, even if you are unable to contact your HMO, get
the care you need. Even if you need to seek care from a
non-HMO provider, your plan will cover emergency care as
long as you follow the plan rules.
Check to see how your plan defines a true emergency. Examples
typically include severe bleeding, chest pain and unconsciousness.
Also check to see how soon after the onset of the emergency
you must notify your HMO in order to be covered.
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Do
I pay a deductible?
A deductible is the part of your eligible
expenses you pay each year before the plan begins to pay
benefits. Check your Benefits Summary for details.
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Do I pay coinsurance?
Coinsurance
is the percentage of eligible expenses you pay after you
meet any deductible required by your plan. Check your Benefits
Summary for details.
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What
is a copayment?
A
copayment is a fixed amount you pay at the time you receive
services.
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What is preauthorization?
Preauthorization
is the process by which an HMO reviews the proposed treatment
and tells you and your doctor how benefits may be paid.
Generally, preauthorized care is paid at the highest level
of coverage.
You must obtain preauthorization for certain covered expenses
such as a hospital stay. If you don't get the required preauthorization,
your cost will be higher because the benefits payable by
the plan will be reduced or the expenses will not be covered
at all.
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What are covered services?
Covered
services are services covered by the plan. No medical plan
covers everything. If you obtain services that are not covered
services, you pay the full cost for those services.
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What is an out-of-pocket maximum?
An
out-of-pocket maximum is the most you would have to pay
out of your own pocket for eligible expenses. Most HMOs
do not have an out-of-pocket maximum. Check your Benefits
Summary for details. With a plan that has an out-of-pocket
maximum, once you reach the out-of-pocket maximum for a
given year, the plan would pay all eligible expenses for
covered services until any lifetime maximum benefit is reached.
Not all expenses count toward an out-of-pocket maximum.
Expenses for services that are not covered under the plan,
amounts over any allowable amount limit, and penalties for
not preauthorizing care when needed would not count toward
your out-of-pocket maximum.
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What is a lifetime maximum?
A lifetime maximum is the most that will
be paid by the plan for covered services for a given plan
member. Not all plans apply a lifetime maximum, and some
plans have different lifetime maximums for different services.
Once you reach the lifetime maximum, you pay all expenses
over that amount.
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