An HMO (Health Maintenance Organization) is a collection of hospitals, doctors, and other health services all organized under one network. If your health plan is an HMO plan, you pick one primary care physician. All your health care services go through that doctor and you need a referral before you can see any other health care professional, except in an emergency. Visits to health care professionals outside of your network typically aren’t covered by HMO plan. Coordinating all your health care through your primary care physician means less paperwork and lower health care costs for everyone.
There are several different types of HMOs:
- Group Model HMO – An HMO that contracts with a single multi-specialty medical group to provide care to the HMO’s membership. The HMO pays the medical group a negotiated, per capita rate, which the group distributes among its physicians, usually on a salaried basis.
- Staff Model HMO – A type of closed-panel HMO (where patients can receive services only through a limited number of providers) in which physicians are employees of the HMO. The physicians see patients in the HMO’s own facilities.
- Network Model HMO – An HMO model that contracts with multiple physician groups to provide services to HMO members; may involve large single and multi-specialty groups.
- Individual Practice Association (IPA) HMO – A type of health care provider organization composed of a group of independent practicing physicians who maintain their own offices and band together for the purpose of contracting their services to HMOs.
Point-of-Service (POS) plan
A POS plan is an “HMO/PPO” hybrid; sometimes referred to as an “open-ended” HMO. POS plans resemble HMOs for in-network services. Services received outside of the network are usually reimbursed based on a fee schedule or usual, customary and reasonable charges.
EPO stands for Exclusive Provider Organization. EPO is a more restrictive type of preferred provider organization plan under which there is no coverage for care received from a non-network provider except in an emergency situation.
PPO vs. HMO
If you’re looking at an HMO, take a close look at the network to determine if the choices of doctors and medical facilities will meet your needs. A PPO gives you more freedom, including the potential to be covered for medical bills outside the network, but your costs may be higher.