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Affordable Health Maintenance Organization Plans
The most well-known plans in the U.S. are HMO (or Health Maintenance Organization plans), which enroll about 64.5 million people per year.
HMO plans offer a range of services for a monthly premium, such as preventive care, lab tests, emergency care, surgery or hospital stays. The limitation is that all care must be provided within a network of doctors, usually coordinated by the patient’s primary doctor within the network. If you want to see a specialist, you will 1usually need to see the primary doctor to get a written referral first.
The benefit of HMO plans is that they’re easy to use and cover most of your expenses. Many have high premiums, but little to no deductibles. You can often change your doctor from month to month if you don’t like the physician assigned to you. When you see your doctor you simply show your health insurance card and pay a minimal co-pay along with your visit.
What HMO Plans Cover
Different HMO plans offer different types of preventive and long-term coverage. In general, they cover doctor visits, hospital stays, lab tests, emergency care, surgery, and preventive care. Not all plans will cover all kinds of preventive services.
The HMO Provider Network
HMO plans are an example of managed care, where administrators have control over the coverage and partnerships with providers such as hospitals and doctors. Some HMOs hire staff doctors and specialists, while others contract with individual doctors to provide coverage.
Since the list of doctors is limited, doctors may often get very busy, and patients may need to make an appointment a couple of weeks in advance to see a doctor. Administrators may also need to check to make sure that the services are covered under a particular HMO policy. For example, if a doctor recommends a certain surgery, then the insurance plan may need to approve it as “medically necessary” before the surgery is performed.
If a patient wants to see a doctor outside the network, then he or she will need to check to see whether the insurance will help cover the cost.
HMO Plans and Prescription Coverage
HMO plans usually offer some types of prescription coverage, so they’re a good choice for people who need regular prescription. Each insurance plan usually has a list of prescriptions they cover, which are classified into three groups:
- Generic drugs
- Formulary
- Non-formulary drugs
Different co-payments apply to each classification. If you’re switching plans, you may be surprised to find that a new plan does not cover the medication you’re used to using, so check the list before you apply.
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Affordable-Health-Insurance.com is an informational resource only and not an insurer or broker. The information on this site is provided for research purposes only, and is not necessarily affiliated with any specific carrier. We are not necessarily associated with any provider profiled on our site, and make no guarantees about the carrier affiliation of any broker that contacts you. Coverage options and policies may not be available in every state, and no guarantees of the same are made herein.
