What is an HMO?

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What is an HMO?

An HMO, or Health Maintenance Organization, is an organization involved with providing some kind of medical insurance using a prepaid payment program.  For companies and employers of more than 25 people, the U.S. government basically requires them to provide HMO medical insurance options to their employees.

One basic feature of the insurance that people can get from an HMO is the so-called primary care physician.  In most cases, a family doctor or internal medicine practitioner is the designated primary care physician. The HMO membership typically requires people or employees to consult with this particular doctor to receive the medical insurance benefits.  The primary care doctor also decides if it is necessary that a particular employee be referred to another doctor or specialist regarding a special condition or ailment.  Referrals are also made to doctors who are part of the specific HMO network or those who chose to accredit themselves and agree with standard HMO guidelines.  With the primary care physician feature, people who receive their benefits from an HMO are restricted in terms of choosing their own doctor for their medical concerns.

Basic coverage for people who have medical insurance under HMOs depends on a per company or organization basis.  Some companies may have specific benefit limits while others may have restrictions in terms of medical procedures, hospital charges, or prescription coverage.  The best thing about HMOs is that the insurance costs are typically low, and the coverage is guaranteed as long as the guidelines are followed.  Extra fees or additional payments may be necessary, though, if a person decides to consult with a non-accredited doctor at a facility that is not part of the HMO network.  There are also concerns regarding the provision for the best possible care by the appropriate doctors since people are required to go to a designated primary care physician.  For this reason, patients may not be referred to the appropriate specialist and therefore not get the best medical options available in their care.

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