What Is an HMO and How Does It Work?
What is an HMO? HMO stands for health maintenance organization. HMOs have their own network of doctors, hospitals and other healthcare providers who have agreed to accept payment at a certain level for any services they provide. This allows the HMO to keep costs in check for its members. A health maintenance organization (HMO) is a health insurance plan that provides health services through a network of doctors for a monthly or annual fee.
A Health Maintenance Organization HMO health plan offers a local network of doctors and hospitals for you to choose from. For example, if you have a chronic health issue, you need to visit your PCP first. Your PCP may then refer you to an in-network specialist for care. Louis, Inc. Plans contain exclusions and limitations and may not be available in all areas. For costs and details of coverage, see your plan documents. All insurance how to breed a moon dragon and group benefit plans contain exclusions and insjrance.
For availability, costs and complete details of coverage, contact a licensed agent or Cigna sales representative. This website is not intended for residents of New Mexico. Selecting these links will take you away from Cigna. Cigna may not control the content or links of non-Cigna websites. For the best experience on Cigna. Overview Medicare Coverage Options.
Individuals and Families. Plans and Services. Plans Through Your Employer. What is an Insuarnce Plan? You can change your PCP at any time.
Cigna may need to pre-certify hospitalizations and other outpatient care, but there's no paperwork for you when using in-network providers. I want to All rights reserved. Language Assistance.
Advantages of HMO plans
Read about HMO plans, which require you to go to doctors, other health care providers, or hospitals on the plan's list, unless you need emergency care. You may also need to get a referral from your primary care doctor to see a specialist. If you want Medicare Prescription Drug Coverage (Part D), you must join an HMO that offers prescription drug coverage. What is an HMO Plan? A Health Maintenance Organization (HMO) health plan offers a local network of doctors and hospitals for you to choose from. Each HMO plan includes global emergency and urgent care coverage* 24 hours a day, seven days a week. What Is an HMO? HMO stands for health maintenance organization, a type of managed care health insurance. As the name implies, one of an HMO’s primary goals is to keep its members healthy. Your HMO would rather spend a small amount of money up front preventing illness than a lot of money later while trying to treat it.
In this, more emphasis is placed on prevention and quality of care. In the HMO Plan in health insurance, there is an opportunity to control healthcare costs of managed care. PCP also called the gatekeeper in medical billing. Primary care physician coordinates with all plan members for medical care. If there is a requirement of a specialist for treatment, the primary care physician PCP will refer the patient to a specialist who is usually also in a member of the HMO network.
Patients if go outside of the HMO network to receive treatment or service Unless given prior approval will probably pay all or most of the cost of that care out of their own pockets. In this system health service is provided to each member of the plan for a prior fixed amount. Example like an employer contracts with an HMO to provide healthcare services for its employees and pay this fixed amount charge.
Identifying an HMO member by their ID cards can most easily be accomplished by locating the name of the primary care provider PCP on the card, as well as the co-pay information.
If patient has two insurances and one of the insurance is a HMO of the other insurance then we will bill the HMO only. If patient has Medicare insurance and Evercare then we will Evercare only not Medicare.
If a patient has two insurances and one of the insurance is a HMO, but not a HMO of the other insurance then we will follow the sequence given on the registration form. Many practices must work concurrently with three of the following 4 reimbursement methods.
Capitation is the method used by HMOs and some managed care plans to pay the health care provider a fixed amount on a per capita per person basis. This fee is independent of the number of services rendered to enrolled patient. This reimbursement method was initially provided only to primary care physicians. If the HMO members are healthy and fall sick less, it will make a profit. This is the general or traditional form of reimbursement.
Payment for services may be made by the patient or form a third-party payer. Utilization review is designed to ensure the patient is given all necessary care in the most appropriate health care setting by the most cost effective method. This reimbursement scheme is most often chosen by employers who elect to cut the cost of healthcare through managed care. It is a payment method in which the healthcare provider receives one lump sum amount for all services rendered to the patient for a specific illness.
Example- reimbursement for the global surgical fee paid to physicians who perform major surgery. These global surgical fee payments cover the following services. The main advantage of having an HMO as health insurance is, the plan does not need claim forms when a visit to a doctor or in hospital admission. An HMO plan charges a fixed fee every month so its members can receive health care.
There will be a co-payment amount for each doctor visit, however, with the HMO, fees can be forecasted, unlike a fee-for-service insurance plan. In an HMO Plan, there are some disadvantages. The premium that is paid by the policyholder is only enough to cover the costs of doctors in the network. The major disadvantage of the HMO plan in health insurance or medical billing is that it is difficult to get any specialized care because the get a referral first is a must in each case. Table of Contents.
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