HMO is the short term for health maintenance organization. This is a type of health care organization that provides health insurance for patients by offering them a specific group of physicians, hospitals, and medical facilities to receive their health care from.
These doctors, clinics, and hospitals all belong to the insurer’s network of heath care providers and they all have a contract with the insurance carrier. Patients are asked to visit members of the network when seeking medical attention to make sure they receive their benefits. Health care visits outside of the network aren’t covered under the health insurance plan.
Most of HMO plans require that their members select a PCP, which is a primary care physician. This then becomes their regular doctor for preventative care and routine visits. After the PCP is selected, members of the HMO visit this doctor whenever they need medical attention, unless it’s regarded as an emergency.
The PCP will diagnose patients and if further medical help is needed they will refer them to another doctor or a specialist. If a member of the HMO visits a health care provider without getting a referral from the PCP, it’s likely that the visit won’t be covered by the health plan, even if the doctor or specialist belongs to the carrier’s network.
There are several types of HMO and PPO plans available on the market. A group plan means that the insurer will contract health care providers in a specific geographical region and they will treat patients who live in it. The health care providers are paid a monthly fee for each HMO patient that they treat. However, they can treat patients who don’t belong to the HMO.
If the HMO is known as a captive group plan, the health care providers will treat HMO members only. There is another plan known as a staff model. In this type of HMO the health care providers will provide treatment in a specific medical center which is owned and managed by the HMO itself.