What is a health maintenance organization?

A health maintenance organization (HMO) is defined as either a public or private organization that provides supplemental health care options to its subscribers. The organization contracts with primary care physicians (PCPs), clinics, and specialists to provide care. The HMO and the providers agree on a flat rate of payment between themselves, which allows the HMO to drop premiums for its subscribers. The contracts also allow the organization to provide higher quality care than other health organizations.

It helps to think of a health maintenance organization as a club where you join and you’re assigned to a specific provider. The club has certain rules and regulations for providing coverage. However, as it is like a club, health maintenance organization coverage provides lower costs of non-urgent care. They do this to help you maintain your health. Because, as the adage goes, prevention is worth more than the cure.

What do I need to know about health maintenance organization coverage?

Ask lots of questions when usinghealth maintenance organization coverage

As with any contract, be sure that you are aware of the fine print. Each coverage plan will be a little different depending on the organization and the needs of the applicant. Use the following points as talking points when inquiring about your specific coverage plan needs:

  • Care must be received from inside the HMO network
  • You may be required to live in or work in the plan’s coverage area
  • The HMO may cover urgent care received out of the area
  • You will have to pay out of pocket for non-emergency out-of-network care
  • You are responsible for knowing if the care received is in-network or not
  • At most visits you will have a copay, usually $20 or less
  • Most HMO plans cover prescriptions
  • Most HMO plans require a designated primary care physician
  • If you need to see a specialist, you will require a referral
  • Yearly exams, such as a mammogram do not require a referral

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At Buffalo Health Advisors, we believe in providing solutions to seniors as they transition to Medicare plans. Not only can Medicare Advantage work to protect your health, choosing the right plan can go a long way toward protecting your wealth. This plan is critical if you are going to be living on a fixed income during your retirement years.

It will cost you nothing to learn more about the options available to you. Call or stop by our Nashville, TN office to discuss your Medicare plan options with one of our experienced agents.

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Compare Medicare Advantage plans to find the best match for your personal needs with no obligation!

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