VISTA HEALTH LEARNING CENTER
WHAT IS AN HMO?
A health maintenance organization (HMO) is a type of Managed Care Organization (MCO) that provides a form of health insurance coverage in the United States and Switzerland that is fulfilled through hospitals, doctors, and other providers with which the HMO has a contract. Unlike traditional indemnity insurance, care provided in an HMO generally follows a set of care guidelines provided through the HMO's network of providers. Under this model, providers contract with an HMO to receive more patients and in return usually agree to provide services at a discount. This arrangement allows the HMO to charge a lower monthly premium, which is an advantage over indemnity insurance, provided that its members are willing to abide by the additional restrictions.
In addition to using their contracts with providers for services at a lower price, HMOs hope to gain an advantage over every day insurance plans by managing their patients' health care and reducing unnecessary services. To achieve this, most HMOs require members to select a primary care physician, a doctor who acts as a "gatekeeper" to medical services. PCPs are usually internists, pediatricians, family doctors, or general practitioners. In a typical HMO, most medical needs must first go through the PCP, who authorizes referrals to specialists or other doctors if deemed necessary. Emergency medical care does not require prior authorization from a PCP, and many plans also allow women to select, in addition to a PCP, an OB/GYN whom they may see without referral.
HMOs also manage care through utilization review. The amount of utilization is usually expressed as a number of visits or services or a dollar amount per member per month. Utilization review is intended to identify providers providing an unusually high amount of services, in which case some services may not be medically necessary, or an unusually low amount of services, in which case patients may not be receiving appropriate care and are in danger of worsening a condition. HMOs often provide preventive care for a lower co-payment or for free, in order to keep members from developing a preventable condition that would require a great deal of medical services. When HMOs were coming into existence, indemnity plans often did not cover preventive services, such as immunizations, well-baby checkups, mammograms, or physicals. It is this inclusion of services intended to maintain a member's health that gave the HMO its name. Some services, such as outpatient mental health care, are often provided on a limited basis, and more costly forms of care, diagnosis, or treatment may not be covered. Experimental treatments and elective services that are not medically necessary (such as elective plastic surgery) are almost never covered.
Other methods for managing care are case management, in which patients with catastrophic cases are identified, or disease management, in which patients with certain chronic diseases like diabetes, asthma, or some forms of cancer are identified. In either case, the HMO takes a greater level of involvement in the patient's care, assigning a case manager to the patient or a group of patients to ensure that no two providers provide overlapping care, and to ensure that the patient is receiving appropriate treatment, so that the condition does not get worse beyond what can be helped.
HMOs often shift some financial risk to providers through a system called capitation, where certain providers (usually PCPs) receive a fixed payment per member per month and in return provide certain services for free. Under this arrangement, the provider does not have the incentive to provide unnecessary care, as he will not receive any additional payment for the care. Some plans offer a bonus to providers whose care meets a predetermined level of quality.
Some critics regard HMOs as monopolies that distort the market for health care. They argue that HMOs were supposed to be a stopgap solution, and perhaps even set up for ultimate failure so the public would demand that the federal government would take over with a national health care system.
Retrieved from http://en.wikipedia.org/wiki/Health_maintenance_organization
Relevant Links
New York State Insurance Department
The Insurance Department is responsible for supervising and regulating all insurance business in New York State.
http://www.ins.state.ny.us/hp97wel.htm
Healthy New York
Healthy NY is a state program that offers subsidized and standardized insurance plans (offered by all HMO's) to qualifying Individuals, Sole Proprietorships & small Groups.
http://www.ins.state.ny.us/healthny.htm
Child Health Plus
New York State has a health insurance plan for kids, called Child Health Plus. Depending on your family's income, your child may be eligible.
http://www.health.state.ny.us/nysdoh/chplus/
Elederly Pharmaceutical Insurance Coverage (Epic) Program
EPIC is a New York State sponsored prescription plan for senior citizens who need help paying for their prescriptions.
http://www.health.state.ny.us/nysdoh/epic/faq.htm