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How To Choose An HMO That's Right For You

Managed care plans have come a long way since their inception. Health maintenance organizations or, more familiarly, HMOs have blazed the trail for these types of health insurance plans and have brought them into the mainstream. But is this type of health care coverage right for you?

This page:

  Describes how HMOs work, and how they affect your cost and care

  Lists advantages and disadvantages of an HMO

  Provides some criteria to use when shopping for an HMO

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The search for the best coverage at the lowest price starts with comparing as many plans as possible from providers in your area.

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Do You Qualify For A Subsidy?

Find out if you qualify for a government subsidy under Obamacare. Millions of Americans will have their insurance rates reduced under the new health care law. Learn how much you could save with our simple calculator.

How an HMO works

When you join an HMO, you pay a fixed monthly fee, called a premium. In return, the health insurance company and its health care network provide a variety of medical benefits.

The range of health care services covered by an HMO varies, so it is important to compare available plans. Some health care services, such as outpatient mental health care, are often only covered on a limited basis.

Health maintenance organizations are defined partially by its network of physicians and facilities. From this list, you choose a primary care physician, who is then responsible for your health care as well as for making referrals to specialists and approving any further medical treatment necessary.

Usually, your choice of doctors and hospitals is limited to those on the list - since they have agreements with the HMO to provide your health care. However, exceptions may be made in emergencies or when medically necessary.

Generally, the health care services offered will require you to make a co-payment. A common example of a payment for services within the HMO is five to twenty dollars per doctor visit and five to ten dollars for prescriptions. Some health insurance plans and some services charge nothing. The drawback of any HMO policy is that no care received outside of the health care network that is not pre-approved by your primary caregiver is covered.

Advantages and disadvantages of HMO health insurance

Many people like HMO health insurance because they do not require claim forms for office visits or hospital stays. Instead, HMO members present a card, like a credit card, at the doctor's office or hospital. However, insurance through an HMO you may have you waiting longer for a doctor's appointment than you would with an indemnity insurance plan in non-emergency situations.

Because the HMO health insurance company charges a fixed fee for your health care, it is in their interest to make sure you get basic health care for your medical problems before they become serious.

Although there may be a small copayment for each office visit, your total health care costs will likely be lower and more predictable in an HMO than with fee-for-service insurance.

Unfortunately, there are drawbacks to these health insurance plans, too. It is difficult, and sometimes complicated, to get specialized care under an HMO plan since you must first obtain a network referral from you primary caregiver. Any health care cost from other providers, except in emergencies, not covered much or simply not covered at all. The most problematic situation here is emergency care, the coverage for which is strictly limited.

The cost of an HMO

Since an HMO exercises more control over your health care than other managed care plans, the cost is also more controlled. On top of the monthly health insurance premium, there are very few other fees when using the HMO's network of providers. For health care services covered under the plan, HMO's require you to make minimal co-payments for services rendered.

Non-network care, however, is rarely ever covered. Instead, you are responsible for paying the entire medical bill.

In just a couple of minutes, you can get a pretty good idea of what HMO coverage for you and/or your family would cost. Just visit at eHealthInsurance and start a free quote.

Questions to Ask About an HMO

If you are struggling with how to evaluate the quality of your HMO plan, or if you need to compare an HMO versus PPO, use the list of questions below as a guide. If, for any reason, the policy does not answer any question to your satisfaction or the company's information on health maintenance organizations is lacking, be hesitant about purchasing it until they have answered your questions to your complete satisfaction. And then double check your question, just to be sure.

  How many doctors can I choose from?
  Is the network made up of private or group practice physicians?
  Which doctors are accepting new patients?
  Can I change my primary care physician?
  What is the procedure for referrals to specialists?
  How easy is it to get an appointment?
  How far in advance must routine visits be scheduled?
  What arrangements are there for handling emergency care?
  What health care services are offered?
  Are there limits to medical tests, surgery, or other services?
  What happens if a special service is needed but not covered?
  Where are the hospitals that that are within the network located?
  What happens if you're out of town and need medical attention?
  What is the yearly total for monthly premiums?
  Are there any copayments? For which services and how much?

For your convenience, we've prepared a printer-friendly version of the above questionnaire, so that you can fill out answers and compare different plans in a more in-depth manner than you could when comparing just the marketing material provided by insurance companies.

Finding an HMO to suit your medical needs and budget

HMO premiums can vary considerably, even within the same state.

The best way to save on your own payments, is to compare as many plans and companies as possible. (Though keep in mind that in some areas this may be difficult).

You can get an instant health insurance quote from eHealthInsurance, or you can get information directly from local agents who will provide you with tailored premium quotes.

next: PPO plans: the insurance for those who want more choice


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This internet site provides information of a general nature for educational purposes only and is not intended to be legal advice. We make no guarantees as to the validity of the information presented. Your particular facts and circumstances, and changes in the law, must be considered when applying insurance law. You should always consult with a competent insurance professional licensed in your state with respect to your particular situation.