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FAQ's


HMO

What is a Health Maintenance Organization (HMO) and how does it work?
What is a primary care physician (PCP)?
What are the advantages of an HMO plan?
How does an HMO work when I obtain care outside the HMO?
My plan requires me to select a PCP when I enroll. How do I do so?
Can I change my PCP?
Do I ever need to file a claim form with an HMO?
What happens if I need specialty care that is not available from my HMO?
What happens in an emergency?
What happens if I need care while I'm traveling?
Do I pay a deductible?
Do I pay coinsurance?
What is a copayment?
What is preauthorization?
What are covered services?
What is an out-of-pocket maximum?
What is a lifetime maximum?



What is a Health Maintenance Organization (HMO) and how does it work?

A Health Maintenance Organization (HMO) provides health care services to enrolled members through a panel of HMO providers. When you enroll in an HMO, you select a participating PCP for each enrolled family member. You may select any participating PCP from your HMO's provider directory. Your PCP coordinates your medical care, either by providing that care or by issuing a referral to another provider. With an HMO plan, you generally pay a fixed amount each time you receive care. Coinsurance typically does not apply with an HMO.

Except in an emergency as defined by the plan, or with previous approval through the plan's authorization procedures, only services provided by or referred by your PCP will be covered under an HMO.

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What is a primary care physician (PCP)?

With some HMOs, you are asked to select a primary care physician (PCP) to be the personal doctor for each enrolled family member. If you are asked to select a PCP, you may select any participating PCP from your HMO's provider directory.

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What are the advantages of an HMO plan?

There are several advantages when you belong to an HMO. Generally:
You don't need to submit claim forms and wait to be reimbursed by your plan.
Your HMO provider obtains any needed precertification for you.
In most cases, you only pay a copayment (fixed dollar amount) at the time you receive covered services. After you pay your copayment, you owe no more payments for the covered services.
HMO plans typically cover certain preventive care services

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How does an HMO work when I obtain care outside the HMO?

Generally, HMO plans do not cover services provided outside the HMO except in certain emergency situations.

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My plan requires me to select a PCP when I enroll. How do I do so?

When you enroll, you may select any PCP (primary care physician) from your HMO's network provider directory for each covered family member. Your enrollment materials will request your PCP's name, or a code for that PCP from the network provider directory. You will generally find PCPs in the areas of family practice, general practice, internal medicine, or pediatrics. Some plans allow a woman to name one PCP for her primary care and a second specialist in Obstetrics and Gynecology for services such as pelvic exams and Pap smears.

It's a good idea to check with your HMO before you select a PCP. Some PCPs have "full" practices and cannot accept new patients, and others may no longer be participating in the network.

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Can I change my PCP?

Yes. You or a covered family member may change PCPs for any reason. Just call the member services number on your ID card.

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Do I ever need to file a claim form with an HMO?

You generally don't need to file a claim form when you see your PCP. Just show your ID card when you receive services so the office knows to charge you a co-payment and bill your HMO plan for the balance. The plan works the same way when your PCP refers you to another HMO doctor or hospital for care. Just show your ID card and pay your co-payment.

In a true emergency, your eligible expenses may be covered even if you had to go outside the HMO as long as you follow the HMO plan's rules. In this case, the provider will bill you directly. You then need to submit a claim form to be reimbursed. You will be reimbursed for part of the bill.

To file a claim, follow the instructions on the claim form. If you received an Explanation of Benefits (EOB) statement from another health care company, be sure to include a copy with your claim form.
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What happens if I need specialty care that is not available from my HMO?

You may be referred to a non-HMO provider if you need specialized care that your HMO determines to be medically necessary and the care is not available through the HMO in your area. As long as you use the provider you're referred to by your HMO and follow your HMOs rules, you'll be covered for that care.

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What happens in an emergency?

In a true emergency, get the care you need as quickly as you can. Assuming you are able, try to contact your HMO, even in an emergency. However, even if you are unable to contact your HMO, get the care you need. Even if you need to seek care from a non-HMO provider, your plan will cover emergency care as long as you follow the plan rules.

Check to see how your plan defines a true emergency. Examples typically include severe bleeding, chest pain and unconsciousness. Also check to see how soon after the onset of the emergency you must notify your HMO in order to be covered.

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What happens if I need care while I'm traveling?

If it's not an emergency and you need care while traveling, call your HMO and your HMO can help you arrange a referral.

In a true emergency, get the care you need as quickly as you can. If you are able, contact your HMO, even in an emergency. However, even if you are unable to contact your HMO, get the care you need. Even if you need to seek care from a non-HMO provider, your plan will cover emergency care as long as you follow the plan rules.

Check to see how your plan defines a true emergency. Examples typically include severe bleeding, chest pain and unconsciousness. Also check to see how soon after the onset of the emergency you must notify your HMO in order to be covered.

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Do I pay a deductible?

A deductible is the part of your eligible expenses you pay each year before the plan begins to pay benefits. Check your Benefits Summary for details.

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Do I pay coinsurance?

Coinsurance is the percentage of eligible expenses you pay after you meet any deductible required by your plan. Check your Benefits Summary for details.

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What is a copayment?

A copayment is a fixed amount you pay at the time you receive services.

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What is preauthorization?

Preauthorization is the process by which an HMO reviews the proposed treatment and tells you and your doctor how benefits may be paid. Generally, preauthorized care is paid at the highest level of coverage.

You must obtain preauthorization for certain covered expenses such as a hospital stay. If you don't get the required preauthorization, your cost will be higher because the benefits payable by the plan will be reduced or the expenses will not be covered at all.

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What are covered services?

Covered services are services covered by the plan. No medical plan covers everything. If you obtain services that are not covered services, you pay the full cost for those services.

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What is an out-of-pocket maximum?

An out-of-pocket maximum is the most you would have to pay out of your own pocket for eligible expenses. Most HMOs do not have an out-of-pocket maximum. Check your Benefits Summary for details. With a plan that has an out-of-pocket maximum, once you reach the out-of-pocket maximum for a given year, the plan would pay all eligible expenses for covered services until any lifetime maximum benefit is reached.

Not all expenses count toward an out-of-pocket maximum. Expenses for services that are not covered under the plan, amounts over any allowable amount limit, and penalties for not preauthorizing care when needed would not count toward your out-of-pocket maximum.

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What is a lifetime maximum?

A lifetime maximum is the most that will be paid by the plan for covered services for a given plan member. Not all plans apply a lifetime maximum, and some plans have different lifetime maximums for different services. Once you reach the lifetime maximum, you pay all expenses over that amount.

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