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HMO (Health Maintenance
Organizations)As
medical and health costs have risen, the number HMO’s has
risen correspondingly. HMO’s provide a one payer managed
health care plan using a prepaid model that emphasizes early treatment
and prevention. The consumer pays a monthly fee for
preventative care including routine physicals, diagnostic
screening.
The HMO comprises medical practitioners who provide specific services to HMO members at prices that are pre-set and the HMO member agrees to pay the HMO a specified amount in advance to cover necessary services. This emphasis on prevention and to reduce costs is the major reason for the development of HMO's. HMO’s enter into contracts with facilities and health care providers to provide services to subscribers. There are usually four types: Group At first this was the most dominant type of HMO. Within the Group Model the HMO contracts with independent medical groups that specialize in a variety of medical services. The HMO then provides these services to its subscribers. In other words, the HMO is paying other entities to provide the medical services rather than hiring them directly. Staff In the staff model the physicians are paid employees working on the staff in a clinical setting at the HMO facilities. The hospital is often owned by the HMO.. The HMO is taking all the financial risk by providing the medical care and financial as opposed to the group model. Network The network model works exactly like the Group model except that the HMO contracts with more than one group to provide the services. Convenience and increased accessibility for subscribers is the reason for the network. Individual Practice Association This model structure is engineered to give maximum flexibility to the HMO subscribers. They are able to contract with individual medical service providers for all services. The HMO does not have its own facilities and all services are provided individually.
There
a number of groups that may sponsor HMO's: Consumer groups Government entities Hospitals Insurance companies Labor groups Labor unions Medical schools or associations Physicians Service organizations (Blue Cross/Blue Shield)
As
a rule HMO’s restrict membership to a strictly defined
group. For example, a labor union usually limits enrolment to
active members of their union. Emergency services Diagnostic laboratory services Diagnostic and therapeutic radiology services Hospital inpatient services Outpatient medical services Physicians’ services Preventive services
Dental care Home health care Long-term care Mental health care Nursing services Prescription drugs Vision care Substance abuse services Supplemental services may purchased from many HMO’s in addition to basic health care services. Co-payments - Nominal amounts for basic services may be charged to HMO members in additional to their monthly payments. Sometimes there may not be such a requirement. A certificate of coverage or evidence of coverage will outline all coverage and payments required. Gatekeeper - Often an HMO's will assign a primary care physician to a member or insured and that physician must authorize all care for a member including referrals to specialists. Twenty four hour access - Most HMO’s allow members 24 hour access to the HMO services. . Open Enrolment - This term can apply in one of two ways. The first is an employee sponsored group that has a set time period in each year when employees may choose to enroll or remain enrolled or change plans. The second is a period in each year when an HMO must advertise to the general public on an individual basis. Non-discrimination - When HMO services are offered to a group, the HMO may not refuse to cover any individual member of the group due to pre-existing health conditions. This differs radically from most traditional insurers who may exclude coverage or deny enrollment for anyone with a pre-existing condition. Prohibitive practices – HMO’s are prohibited from canceling member coverage because of their current health status or usage of health services. HMOs are also prohibited from using language that may imply that the HMO provides insurance in the traditional manner. Complaints - Each HMO must have a grievance system to handle coverage and care complaints. Members must receive a written document that outlines how complaints are to be handled. |
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