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Insurance
About HMOs
By the California Office of the Patient Advocate
What is an HMO?
HMO - Health Maintenance Organization
This is a broad term that, in general, refers to any organized plan other than a traditional health insurance company that provides for your health care. Some plans are very tightly structured so that all care is provided by the HMO's employees in the HMO's hospitals or clinics, while other plans are cooperative agreements among independent doctors, hospitals and other health care providers.
Tips on exercising your HMO rights
When dealing with your HMO:
- Know the name of the HMO that provides your health coverage.
- Know how to contact your HMO.
- Know what type of coverage you or your employer have bought for you. Again, this information will be in your evidence of coverage Your HMO must cover what it said it will cover when you bought the insurance, but you should have some familiarity with what those services are.
- Take the time to read your plan's evidence of coverage. This document is usually mailed to you by your plan and it tells you what you are entitled to under the plan you bought. You can hold your plan to its word through this document!
- Keep all the paper work your plan sends to you. Keep all of it in one place and be familiar with it. If there are things you do not understand, call the plan's customer service department (the number will be in the evidence of coverage and on the HMO patient membership card). If you get your health insurance through your employer, the personnel department may be able to answer some of your questions.
- Become familiar with your plan's grievance process. A grievance is a formal way of filing a complaint with your plan if you are not satisfied. This process is required by law, and your evidence of coverage will include an explanation of what you have to do to file a grievance with the plan. Click here to find your HMO's grievance number.
- As a patient, you have Rights and Responsibilities. Know what they are. Know what you have to do, and what your HMO has to do in order for you to get the best health care possible.
Be well-informed! Read, ask, explore!
Tips on dealing with your doctor:
- Many HMOs require you to choose a primary care physician. That doctor will be your main contact with the HMO when it comes to medical matters. Make sure you find one you will get along with. Sometimes you will simply pick a name off a list, or the HMO will assign a primary care physician to you. Get to know that doctor over a couple of visits. If you like him or her, fine. If you don't, talk to people who are in the same HMO, or the same medical group as you to see if they can recommend a doctor they might know about. See if someone at the HMO or medical group can suggest someone.
- Be respectful of your doctor's time. Health plan doctors work under time pressure since they have many patients to see, and want to give each of them the best care possible.
- When visiting your doctor, always make sure you are ready to use your time wisely. Have your concerns written down. What are your symptoms, what are your worries, what are your expectations? Ask all the questions that are important to you, and be honest and open with your doctor if he or she has questions for you. Don't be rushed if there's something that is on your mind that you haven't gotten to.
- If you think you need to see a specialist, you will have to discuss this with your primary care physician. Most HMOs require the primary care physician to approve appointments with specialists.
- If you are not sure your doctor is right about a diagnosis or course of treatment, especially if it involves a major procedure like surgery, you have the right to see another doctor for a second opinion. In many cases, the HMO will pay for this. A second opinion might confirm what your first doctor said, but in some cases the second doctor sees something the first doctor missed, or knows something the first doctor doesn't.
- If your health plan does not allow you to get a second opinion, ask for an explanation and ask them to put it in writing.
- Once again, be familiar with your plan's grievance process. If you do not agree with any medical decision, the plan's grievance process is designed as the first step in resolving the problem.
Be an active participant in your own health care. Read about your medical problem. Help your Doctor Help You.
HMO Glossary
EOC or SPD - Evidence of Coverage or Summary Plan Description (SPD). These documents are the most important documents you will receive from your HMO. Make sure you read them and know where they are. Evidence of Coverage is a complete document, while a Summary Plan Description simply summarizes your contract with the health plan. Your EOC or SPD explains your health care benefits, any limits to your coverage, the health plan's policies and procedures and what costs you will have to pay. Click here for more information about these important documents.
FFS - Fee for Service. This is the "traditional" form of health insurance, where you (or your employer) pay a monthly premium to the insurance company, and your doctor is paid by the insurance company for any service he or she provides.
HMO - Health Maintenance Organization. This is a broad term that, in general, refers to any organized plan other than a traditional health insurance company that provides for your health care. Some plans are very tightly structured so that all care is provided by the HMO's employees in the HMO's hospitals or clinics, while other plans are cooperative agreements among independent doctors, hospitals and other health care providers.
IPA or Medical Group - IPA stands for Independent Practice Association, which is a group of independent doctors who work together to provide care and negotiate how much they will be paid by an HMO. Medical Groups are generally more highly structured groups of doctors, but they have banded together for the same reason groups of doctors join IPAs - to provide care to patients and negotiate payment rates with HMOs.
It is critically important for patients to understand whether the organization they are dealing with is the HMO itself, or the Medical Group or IPA. Many times, the HMO will delegate authority to the group of physicians actually providing care, which means that the HMO itself is not claiming responsibility for the final decision. Other times, however, the HMO is the final decision maker. Patients should understand who has the final say - the HMO or the physician group.
PCP - The Primary Care Provider is the doctor who is primarily in charge of your care. If you need to see a specialist, or need lab tests, many HMOs require your Primary Care Provider to approve them. When you first sign up with an HMO, you will be asked to choose a PCP. If you don't, some plans will assign one to you. In either case, you can always change your PCP if you want to. This doctor will be in charge of your health care, so it is important to find one you feel comfortable with. It is generally best to try and get to know your doctor over a couple of visits, but if you are unhappy for any reason, find out from your HMO what you need to do to choose another PCP.
In any event make sure you know who your PCP is, if your HMO requires you to have one.
PPO - Preferred Provider Organization. This is a particular kind of HMO which allows patients a greater selection of doctors. The cost to the patient depends on whether the patient goes to one of the plan's "preferred" providers (in which case the patient pays a lower cost) or some other health care provider (in which case the patient pays a higher cost).
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