The Fundamentals of Health Maintenance Organizations (HMOs)

Most health insurance policies are either health maintenance organizations (HMOs) or preferred provider organizations (PPOs). Point-of-service (POS) plans are something of a hybrid between the two. There are fundamental differences between HMOs and PPOs. Your choice of healthcare plan may come down to your budget and personal preference.

Your Plan May Determine Your Doctors

When you enroll in an HMO plan, you typically limit yourself to one "gatekeeper" doctor, selected from a network, who becomes your primary care physician (PCP). To get treatment from anyone else, like a specialist, you need a referral from your PCP. Typically, this referral will be to another doctor in the HMO network. An exception exists for emergencies. Your PCP should be available to you around the clock, seven days a week, at least by phone. A PPO, on the other hand, is usually a larger organization with more doctors to choose from. Usually, you don't need a referral if you want to see another doctor or a specialist. POS plans require referrals, but the referral can be to a physician who is outside the POS network.

HMOs May Cover More

An HMO usually offers a broad range of healthcare services, ranging from preventative medicine and regular checkups to diagnostic procedures, hospitalization, and even mental health care. An HMO may not deny coverage for pre-existing conditions. A PPO can. If your HMO attempts to deny coverage, you may need legal help.

HMOs Usually Cost Less

When you select a PPO, you'll pay more for the freedom of choosing your own healthcare providers. Both HMO and PPO plans may involve co-payments and co-insurance. With an HMO, the co-payment is the same every time you see your doctor. You won't have any surprises. The amount a PPO can require as co-insurance can vary. How much the PPO will contribute to your healthcare costs may depend on whether the PPO believes the cost of your treatment is reasonable. This is especially true if you go out of network for care. Deductibles (medical bills you must pay for yourself each year before your insurance kicks in) are usually lower or nonexistent for HMO plans.

There May Be a Wait for Coverage

Although an HMO can't deny you treatment for pre-existing conditions, it can make you wait up to three months for treatment after your group plan coverage begins. If you do have a pre-existing condition that requires active treatment, this could be risky. However, you don't have to pay any premiums during this time.

An Insurance Lawyer Can Help

The law surrounding coverage under HMO, PPO, and POS healthcare plans is complicated. Plus, the facts of each case are unique. This article provides a brief, general introduction to the topic. For more detailed, specific information, please contact an insurance lawyer.

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