HMO Is Not a Four-Letter Word

 By Marc Manor

In the course of talking to people about Healthcare or Medicare Plans, I sometimes hear the words “no-way!” when the subject of HMOs or Health Maintenance Organizations come up.  In certain circumstances, after hearing why this immediate response was given, I totally understand.  Other times, I think these negative opinions are derived from “urban legends” or based on “what happened to my friend’s friend.”  Anyone could have a bad experience for any number of reasons on any type healthcare plan.  A healthcare plan is not necessarily bad just because it’s an HMO.  It may not be the right fit for some people; however, there are some things you should know before you just write-off a plan just because it is an HMO. 

Everyone has their own unique requirements for healthcare, and there are a number of factors to consider when choosing a health plan of any kind.  There are advantages to having an HMO; most notably, a managed and coordinated care network among Primary Care Providers (PCPs) and specialists.  So, before you deem HMO a four-letter word, check the facts and find out if you can benefit from an HMO plan.

Here are some things to consider:

The Family Doc

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One of the first things I always ask someone when assessing if an HMO is a good fit is: “Do you have a family doctor you have been seeing?”  This is very important because in an HMO plan, you will likely have to select a Primary Care Provider (PCP) at the time of enrollment and you will probably have to obtain all referrals from that PCP.   If an enrollee has an established relationship with a healthcare provider, the next step is to find a Medicare or Health Plan the provider accepts and is part of the plan network (more on Networks later).  Some providers do not accept HMO plans because they are not contracted with an HMO.  In cases where an enrollee has a long-standing relationship with a provider that is not within the HMO network, the options are to find a different kind of plan or identify a new provider within the HMO network.  There are usually different types of plans available, so a solution can usually be found that allows the enrollee to keep their doctor (I will cover the different types of plans in a later blog).  Changing providers can be a difficult pill to swallow for most folks, but the benefits of an HMO plan may be more important and make the provider change more palatable.  If a new PCP is selected and the enrollee finds later that it is a good fit, a new PCP can be selected as long as they’re in the HMO network.

Networks

HMOs usually operate completely within a network.  This means, in most cases, the plan will not pay claims for services obtained from outside the network (there are some exceptions; for example, in an HMO-POS (Point of Service) plan, members can obtain care outside the network in certain situations). Some HMO’s have very large networks with a number of medical groups operating within it to make a type of network within the network.  This is important when it comes to referrals.  PCP’s may be contracted to make referrals to specialists within the same medical group.  Enrollees who already have relationships with specialists need to be very careful about this when enrolling in an HMO even if their specialist is in the plan’s network because they may not be in the PCP’s medical group. 

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HMO networks and medical groups can be researched with your agent prior to enrollment.  The plans will most likely have online tools to help research this, but I recommend calling the PCP or specialist office to verify your new plan just in case any recent changes to their insurance status has occurred and is not yet reflected online.  This may initially seem feel like a lot of trouble, but in order to take full advantage of the coordinated care the HMO offers, it’s best to take the extra step going in.

Once in the HMO plan, here are some tips to make you the most out of your healthcare plan:

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-       Set an appointment with your PCP. 

o   If you have a new PCP, make a new patient appointment as soon as practical.  Once you check in for your appointment, you can provide your insurance information and have that on file from the beginning.  Once you see your new PCP, let them know about all your existing conditions and discuss specialists if needed.  Usually, the referrals can be generated at that first appointment, allowing you to make appointments with your specialists.  Referrals for dermatology and others that require recurring treatments can usually be authorized by your specialists. 

o   If you are already a patient and you have a new HMO plan, you may be able to put off the appointment; but, be sure to call your PCP office and update them on your new HMO plan.  If you are already seeing specialists, ask your PCP office if you need new authorizations.  I DO NOT recommend seeing specialists you are already seeing until you call your PCP office.  They may require you come in to provide your new insurance information.  Your new HMO plan may not cover your current specialists if not referred using your new/current insurance.

-       Make sure your prescriptions are up-to-date.  Discuss your prescriptions with your PCP to get your refills on track.

-       Become familiar with your Evidence of Coverage (EOC).  Most plans mail this out to you soon after enrolling.  Keep it in a safe place and take the time to become familiar with it.  There is a lot of useful information in the EOC that is way beyond the scope of this blog.  You will gain a much better understanding of your benefits by being familiar with your EOC.

-       Set up an online account.  This applies to any plan, HMO or otherwise.  These days, nearly all plans have online account access.  You can track your claims and usually pay premiums using a secure online system.  Online access is a convenient and fast way to stay current with your benefits.

HMOs are widely available, especially in urban areas where medical groups and networks are robust.  Depending on where you live, you may be able to choose from many HMO plans.  Many people enjoy the managed care aspect and other benefits the HMO offers.  Doing your homework and discussing your concerns with a licensed agent can go a long way toward dispelling the myths and seeing if an HMO is for you.  After all, both the words HMO and YOU only have THREE letters!

Marc Manor is a 30-year military veteran who is now dedicated to teaching his fellow Americans how to make the most of their Medicare and healthcare benefits.  As an independent agent, Marc has access to a wide variety of carriers with an abundance of resources to find tailored solutions.  There is no charge for a consultation so call 904-222-0698 or visit www.manormedisource.com today to stay on course with Medicare education and insurance solutions.

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