A health maintenance organization (HMO) is a health care plan with specific guidelines under which physicians must work and a number of restrictions on what medical professionals a subscriber may use. Although the premiums on these plans are lower than those of traditional health insurance, a consumer is somewhat limited in options.
Those with HMO coverage do pay some of the costs of their medical care, including copays for certain services. If an insured individual chooses to go out of the mandated network to receive treatment, the entire cost of the care received is his or her responsibility. When a person joins an HMO, he or she must pick a primary doctor who acts as the HMO’s representative and chooses what care is needed for the patient. If the individual needs care not offered by the primary doctor, the doctor will refer him or her to a specialist. Emergency room visits are excepted from the referral restrictions. Additionally, women requiring obstetrical or gynaecological care may select their own OB/GYN.
While many patients like the lower premiums, some do not care for the restrictions to choices of medical care providers. Additionally, some feel that primary doctors do not always refer patients when appropriate, resulting in untreated illnesses and conditions.