HMO – Health Maintenance Organization
Generally, a health maintenance organization (HMO) is a type of managed healthcare system. HMO is a prepaid health plan which delivers comprehensive care to members among the designated providers, reduces health care costs by focusing on preventative care and carrying out utilization management controls.
When you choose HMO, you can enjoy the following advantages:
Low costs out-of-pocket
No matter how much medical care is needed in a given month, HMO members pay a fixed monthly fee. Instead of deductibles, HMO usually has some nominal co-payments.
Attention on preventive-care
HMO encourages members to take preventive medical treatment early before health problems become severe.
Health-improvement programs
Many HMO programes hold health education classes and discounted memberships of health club to help the members keep healthy.
HMO not only aims to finance medical care, but also provides the treatment The HMO includes a network of physicians, hospitals, nursing homes, home care agencies and other medical staffs. Doctors, hospitals, and insurers all take part in the business network.
HMO patients pay fixed cost for medical care from providers in network. The insured pays a monthly premium and the HMO covers services such as doctors' visits, hospital stays, emergency care, surgery, checkups, lab tests and x-rays, and therapy. The premium for medicare HMO is $78.20 per month in 2005. You have to pay some co-payment like doctor visits, diagnostic tests and hospital stays. Additionally, you may have to pay membership fee as well.
However, HMO offers several cost advantages when compared with traditional indemnity plans:
- Investigation upon economies of scale to decide the efficient way resources are used and the coordination of some care in one place.
- Less administration and therefore lower expenses.
HMO demands insured to get treatment within the provided network. If you want to get medical treatment outside the network, the HMO will not cover your care, except in some emergencies. But, the member must report the emergency as soon as possible. If you travele to foreign countries, you can not be covered even in an emergency. As a return, HMO supplies lower hospitalization fees and broader coverage such as routine physicals and medical screenings.
Every coin has two sides, so does HMO. So if you join in HMO, you also have to bear its Disadvantages:
Less flexible healthcare provider
When you become an HMO member, you have to choose a primary care physician (PCP), and when you take any medical care the PCP will be your first contact. The primary care physician provides you general medical care and when you want to see some specialists, you must consult the PCP for an agreement. Due to this tight control, HMO tends to decrease its cost much more than other insurance plans, which have been criticized as impersonal treatment and "assembly-line" care for restricting their patients' medical options to control costs.
BLUE SHIELD
Access+ HMO Plan
Features-
- For people who visit the doctor more frequently
- Option to visit a participating specialist without a referral - for a $30 copayment
- Preventive care services at no charge
- Prescription generic drugs only $10 per prescription at participating pharmacies
- Extensive network from which to choose a Primary Care Physician - office visits with your PCP for a $10 copayment
Rates-
| Access + HMO Plan Benefits |
Individual Coverage |
Two-Party/Family Coverage |
| Deductibles |
$1,500 |
$3,000 |
| Physician Services (i.e. office visits) |
$10/visit |
$10/visit |
Prescription Drug Coverage
- Generic Drugs
- Brand-name Formulary Drugs |
$10/prescription $30/prescription |
$10/prescription $30/prescription |
| Monthly Rates |
$170 |
Two-Party - $330
Family - $ 512 |
BLUE CROSS PLAN COMPARISON
|
HMO |
HMO Saver |
| Annual Out-of-Pocket Maximum (includes deductible) |
$3,000 per single |
$3,000 per single |
| Annual Deductible |
No deductible |
$1,500 per member |
| Office Visits |
$10 |
$10 |
| Drug Benefits |
$10 for generic and $30 for Brand drugs, plus a $250 deductible for Brand drugs |
$10 for generic and $30 for Brand drugs, plus a $250 deductible for Brand drugs |
| Monthly Rates |
Individual - $226
Two-Party - $444
Family - $797 |
Individual - $156
Two-Party - $279
Family - $559 |
|
