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Health Maintenance Organizations (also widely referred to as HMOs) is a variation of health benefits distribution, which provides coverage on a fee-for-service basis. Insurance companies that provide HMO coverage plans each have an agreement with certain medical facilities and professionals in order to offer reduced fees to those, who purchase such plans.

What HMO plans are all about?

HMO plans are based around primary care physicians (PCPs) that a person buying such a plan has to choose from the network of medical providers the company works with. The PCP is the person who will manage and coordinate all the actions and services provided to the customer, as well as offer consulting and basic care measures such as check ups and exams. Preventive medical services are usually free of copayments within HMO plans.

In case the health problem of a person exceeds the professional field of knowledge of the PCP, the doctor refers this patient to another physician specialized in that very domain. The said specialist will further investigate the problem and use his expertise to resolve it, but only after he or she receives the referral from the PCP. Otherwise, you won’t be able to receive any medical attention with the exception of situations of critical emergency when the risk of complications is very high.

The coverage you receive through an HMO plan is provided only within the limits of the medical network specified by your provider. In case the member of an HMO plan chooses to receive any medical services in a facility that doesn’t make part of the network, there won’t be any coverage and the person will cover all the expenses in full out of own pocket. Besides, HMO plans will allow you to receive medical care from an additional specialist only when you have the corresponding referral provided by your PCP. Otherwise, this is regarded as using out of network services and your expenses won’t be covered at all even if it’s the same medical facility where your PCP is located. (more…)