HEALTH MAINTENANCE ORGANIZATION
HEALTH MAINTENANCE
ORGANIZATION
HEALTH MAINTENANCE ORGANIZATION (HMO)
• An organization that provides health coverage with providers under contract • Differs from traditional health insurance by the contracts it has with its providers. These contracts allow for premiums to be lower:
• Because the health providers has the advantage of having patients directed to them
• But these contracts also add additional restrictions to the HMO members. • HMOs provide health care to their members through networks of doctors and hospitals.
TYPES OF HMOS
• Prepaid Group Practice model
• In this model, physicians are organized into a group practice, and there is one insuring agency
• Medical Care Foundation (MCF)
• Usually involves a number of insurance companies.
• The organization is a loose network of individual physicians, practicing individually and paid on a fee-for-service basis.
• Reimburses the physicians from the prepaid fees of subscribers. HOW HMOS WORK
• HMOs contract with doctors, hospitals, and clinics to provide health care within specific geographic areas.
• Except for emergencies, you must use doctors in your HMO’s network and within your service area.
• When medically necessary care isn’t available from a network doctor, the HMO may approve a referral to a doctor outside of its network.
• Covered dependents who live outside the service area to attend school will have to travel back to the service area for routine care.
Your Primary Care Physician
• Choose a primary care physician (PCP) from a list of doctors in the HMO’s network. your HMO will give you a list of doctors to choose from
•
•
If you need to see a specialist, or another doctor, you usually get a referral from your PCP.
If you need to see a doctor but your PCP isn’t available, your doctor’s office might ask if you’d like to see
Drug Formularies
• HMOs use drug formularies as a way to control costs.
• A formulary is a list of prescription drugs that an HMO has approved for its doctors to
ORGANIZATION
HEALTH MAINTENANCE ORGANIZATION (HMO)
• An organization that provides health coverage with providers under contract • Differs from traditional health insurance by the contracts it has with its providers. These contracts allow for premiums to be lower:
• Because the health providers has the advantage of having patients directed to them
• But these contracts also add additional restrictions to the HMO members. • HMOs provide health care to their members through networks of doctors and hospitals.
TYPES OF HMOS
• Prepaid Group Practice model
• In this model, physicians are organized into a group practice, and there is one insuring agency
• Medical Care Foundation (MCF)
• Usually involves a number of insurance companies.
• The organization is a loose network of individual physicians, practicing individually and paid on a fee-for-service basis.
• Reimburses the physicians from the prepaid fees of subscribers. HOW HMOS WORK
• HMOs contract with doctors, hospitals, and clinics to provide health care within specific geographic areas.
• Except for emergencies, you must use doctors in your HMO’s network and within your service area.
• When medically necessary care isn’t available from a network doctor, the HMO may approve a referral to a doctor outside of its network.
• Covered dependents who live outside the service area to attend school will have to travel back to the service area for routine care.
Your Primary Care Physician
• Choose a primary care physician (PCP) from a list of doctors in the HMO’s network. your HMO will give you a list of doctors to choose from
•
•
If you need to see a specialist, or another doctor, you usually get a referral from your PCP.
If you need to see a doctor but your PCP isn’t available, your doctor’s office might ask if you’d like to see
Drug Formularies
• HMOs use drug formularies as a way to control costs.
• A formulary is a list of prescription drugs that an HMO has approved for its doctors to