A health maintenance organization (HMO) is a form of comprehensive health insurance
through which members receive care provided by certain doctors, hospitals and other health
care providers who are affiliated with the HMO. These partnerships create a coordinated system
of patient care called a network.
The physicians, hospitals and other health care providers in the network work
together to provide care to the members of the HMO. An HMO coordinates the
patient care given by network providers so it is possible for consumers to get
information on the quality of care each HMO provides. These pages contain that information.
|How a Typical HMO Works|
|How you choose a primary care provider
HMOs require you to choose a primary care provider (PCP) from a list of network providers.
|Who is responsible for the qualifications of physicians |
Before an HMO asks a provider to become part of the network, the HMO verifies the provider's credentials and background.
|How you consult a specialist
In order to see most types of specialists, HMOs require that you get approval for a "referral" from your PCP. Some plans allow you to go to physicians that are not in the network but you pay more.
|Who is responsible for the care patients receive|
In HMOs, each provider makes independent decisions about patient care, but he or she also works with the HMO to make sure that the patient receives the appropriate care.
|How you pay for services
Typically, consumers benefit financially from being a member of an HMO. There is no deductible and the out-of-pocket costs are low for most health care services received in the network. You are charged a pre-set amount (usually between $5 and $25) for a physician office visit. No claim forms need to be filled out.
|How you get services "out of network"|
In a typical HMO you are responsible for the cost of seeing a provider who is not in the network. Many HMOs also offer a point-of-service product that allows members to see out-of-network providers at an additional cost.