Who is eligible for hmo

Make sure you feel comfortable with them or make a switch. In most HMOs, your primary care provider will be the one who decides whether or not you need other types of special care and must make a referral for you to receive it. Referrals will all be within the region where you live. With an HMO, you typically need a referral for the following:. The purpose of the referral is to ensure that the treatments, tests, and specialty care are medically necessary. The benefit of this system is fewer unnecessary services.

The drawback is that you have to see multiple providers a primary care provider before a specialist and pay copays or other cost-sharing for each visit. A copay is a set amount you pay each time you use a particular service. Referrals have long been a feature of HMOs, but some HMOs may drop this requirement and allow you to see certain in-network specialists without one.

Become familiar with your HMO plan and read the fine print. Every HMO has a list of healthcare providers that are in its provider network. Those providers cover a wide range of healthcare services, including doctors, specialists, pharmacies, hospitals, labs, X-ray facilities, and speech therapists.

Accidentally getting out-of-network care can be a costly mistake when you have an HMO. Fill a prescription at an out-of-network pharmacy or get your blood tests done by the wrong lab, and you could be stuck with a bill for hundreds or even thousands of dollars.

It's your responsibility to know which providers are in your HMO's network. And you can't assume that just because a lab is down the hall from your healthcare provider's office, it is in-network. You have to check. And sometimes out-of-network providers end up treating you without you even knowing about it—an assistant surgeon or an anesthesiologist , for example.

If you're planning any sort of medical treatment, ask lots of questions in advance to ensure that everyone who will be involved in your care is in your HMO's network. There are some exceptions to the requirement to stay in-network. This can include:. If you have an HMO and get care out-of-network without getting a referral from your primary care provider, you won't receive coverage unless it's a medical emergency or another exception that's been approved by the HMO. Your HMO would rather spend a small amount of money up front to prevent an illness than a lot of money later to treat it.

If you already have a chronic condition, your HMO will try to manage that condition to keep you as healthy as possible. There are three main types of HMOs. They may also have to pay most of the cost unless they have a referral from a doctor to the out-of-network provider. In addition, if a person goes to an out-of-network healthcare provider, they have to file the paperwork with their HMO-POS company. A person has to pay the provider, and then wait for reimbursement for the allowable charges.

Medicare Part A is hospital insurance and provides coverage for hospital, skilled nursing, and hospice care. Medicare Part B is medical insurance and provides coverage for the diagnosis and treatment of medical conditions, and some preventive services such as flu shots or cancer screening. Medicare Advantage plans must provide coverage for the same benefits offered through original Medicare.

However, Advantage HMOs may offer additional benefits, such as:. A person must be enrolled in original Medicare to be eligible for an Advantage plan. The Centers for Medicare and Medicaid Services CMS added two special enrollment periods for a person enrolled in an Advantage plan who has a consistent record of poor performance, or is having financial problems and the assets are held by a third party called receivership. In addition, there are other eligibility requirements for a person with end stage renal disease ESRD.

From January 1, , changes in the regulations mean that a person with ESRD can enroll in an Advantage plan during any valid enrollment period. People can enroll in a Medicare Advantage plan, including a HMO plan, during several enrollment periods :. HMOs usually have the lowest out-of-pocket costs. These can include premiums, deductibles, coinsurance, and copays.

Once you have joined an HMO, you should receive a benefit card from your plan. You will use your HMO benefit card instead of your Medicare card when you go to the doctor or hospital. In most HMOs, you must see in-network providers to receive coverage, unless you need emergency medical treatment. In these cases, you will be covered but usually at a higher cost. The reason is that patients are encouraged to get annual physicals and to seek out treatment early. If you're paying for an HMO, you're restricted on how you can use the plan.

You'll have to designate a doctor, who will be responsible for your healthcare needs, including your primary care and referrals. This doctor, though, must be part of the network. This means you are responsible for any costs incurred if you see someone out of the network, even if there's no contracted doctor in your area. You'll need referrals for any specialists if you want your HMO to pay for any visits. So if you need to visit a rheumatologist or a dermatologist, your primary doctor must make a referral before you can see one for the plan to pay for your visit.

If not, you're responsible for the entire cost. There are very specific conditions that you must meet for certain medical claims, such as emergencies.

For instance, there are usually very strict definitions of what constitutes an emergency. If your condition doesn't fit the criteria, then the HMO plan won't pay. HMO or health maintenance organization insurance provides covered individuals with health insurance in exchange for monthly or annual fees.

People pay lower premiums than those with other forms of health insurance when they visit doctors and other providers who are part of the HMO's network. Almost every major insurance company provides an HMO plan. The main benefits are cost and quality of care. People who purchase HMO plans benefit from lower premiums than traditional forms of health insurance.

This allows insured parties to get a higher quality of care from providers who are contracted with the organization. HMOs typically come with low or no deductibles and only charge relatively low co-pays. HMO participants also don't need referrals to get specialty services such as mammograms.

Coverage under an HMO is generally pretty restrictive and comes at a lower cost to insured parties. Traditional health insurance, on the other hand, charges higher premiums, higher deductibles, and higher co-pays. But health insurance plans are much more flexible. People with health insurance don't need to have a primary care physician to outline treatment. Health insurance also pays some of the costs for out-of-network providers. There are several restrictions for those covered under HMOs, which is why these plans have such a bad reputation.

For instance, HMOs only allow insured parties to see individuals in their own network, which means they are responsible for the full amount of a visit to any doctor or specialist outside this group. The plan may also require individuals to live in a certain area, This means someone who receives medical service out of the HMO's network must pay for it themselves. The plans also require individuals to choose a primary doctor who determines the kind of treatment patients need. Health insurance is an important consideration for every individual.

Choosing the right plan depends on your personal situation, including your health, finances, and quality of life. You can choose from traditional health insurance, such as the preferred provider organization, or the HMO, also known as the health maintenance organization. The HMO provides insured individuals with lower out-of-pocket costs, but more restrictive conditions, including the doctor you see.

Make sure you weigh out the benefits and disadvantages of the plan, regardless of what you choose. Medical Mutual. PPO Insurance Plans. Kaiser Permanente. PPO Plans - what are the differences?