What Is HMO Health Insurance Coverage?

By Cathy Wilson Posted in Health Insurance News

Let’s Talk HMO

HMO Health Insurance means Health Maintenance Organization. It’s a type of health insurance where its members “prepay” premiums for the HMO health service. The HMO is an organization that assumes legal responsibility for costs of care of the insured and the health care services of its members. The HMO “contracts” with health care providers, doctors, hospitals and other health care professionals. For this reason, HMO members are required to use those health care providers who participate in the network. The services are then coordinated by the PCP (primary care physician) who is chosen by the insured from a list of participating providers.

When your health insurance coverage is provided by an HMO, your PCP will “manage” all medical care, including being referred to specialists such as surgeons and cardiologists. As an insured, if you choose to obtain services and or treatment from a non-network provider, you will be required to pay for most of the cost yourself.  But remember, an HMO can’t require referrals for emergency room care, so an HMO will pay for that treatment without a referral.

The Ins And Out’s Of HMO Coverage

There are certain aspects of a Health Maintenance Organization that an insured should understand. A co-payment is the type of cost sharing when the insured person pays a determined fee for the service or a percent of the amount that is allowed as reimbursement for the covered service. This is sometimes referred to as “co-insurance.”

A deductible is the amount the insured must pay before any insurance payments for covered services begin. Remember, there may be costs, separate from deductibles that apply to certain types of services obtained.  There are also exclusions. These are conditions, situations and other services not covered by the plan.

Although some HMOs are beginning to offer more choices in the plan, once an insured selects a primary care physician, he or she should discuss past history such as pre-existing conditions that could also affect the specifics of the HMO.

Related posts:

  1. What Is A Managed Care Health Insurance Plan?
  2. What Is A Network Based Health Insurance Plan?
  3. What Is An Open Ended HMO For Low Cost Health Insurance?
  4. What Is A Point Of Service Health Insurance Plan?
  5. What Does A Non-network Health Insurance Plan Do And Mean?

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