Public Pay Options for Stroke Care: Health Maintenance Organizations (HMOs)
Health Maintenance Organizations are prepaid health insurance plans that give complete medical coverage for a fixed premium. Knowing whether an HMO is right for the person in your care requires careful study.
Types of HMOs
There are three types of HMOs:
IPA (Individual Practice Associations) Plans--A patient chooses a doctor from a primary care physician list.
POS (Point of Service) Plans--For an extra fee a patient can visit a doctor outside of the network list.
Group Model HMOs--A patient must go to a clinic for treatment.
Remember, HMOs receive the same fees to treat a healthy person as a person with a chronic disease. For some patients with long-term or chronic illness, HMOs may not be a good choice. A patient who has a long-established relationship with a specialist who is not a member of the HMO's network list may not be able to continue to see that specialist.
NOTE: If a Medicare health plan is not meeting the needs of the person in your care, it is not difficult to switch to another plan or to a fee-for-service program.
How To Determine If an HMO Is Right for Your Survivor
- Ask if the doctor or specialist the person is now seeing is in the HMO network.
- Understand the person's medical needs--for special equipment, drugs, and help with activities. Determine if these needs are covered.
- Find out if the HMO is used to dealing with the illness the person has.
- Determine the specific services offered for this type of illness.
- Ask who decides what is medically necessary.
- Ask if there is a special Plan of Care for the illness.
- Ask if the person will get the best drugs for the condition or if generic substitutes will be offered.
- Ask how many people with this type of illness are under the plan in your area.
- Verify that the patient may see the specialists listed in the directory.
- Ask if the plan allows visits to specialists without a primary care doctor's referral.
- If a referral is required, find out how long it lasts and if a new referral is required for every visit.
- Ask what percentage of doctors on the list are board certified (have passed a special test given by the board of their specialty).
- Ask if the doctor has a financial incentive to do tests or to keep the patient from having tests or seeing a specialist.
- Ask if the plan covers visits to doctors outside the plan's referral list. (Out-of-network coverage may be limited to a certain dollar amount.)
- Ask how many doctors in the HMO specialize in geriatric care.
- If the person in your care must travel to a specific locale for extended stays, be sure the HMO allows visits to a different HMO there.
- Ask how the person will be charged if an emergency room visit is needed while traveling.
- Ask about the process for appealing a medical decision.
- Once you have decided on an HMO, get confirmation in writing regarding the items or services that are most important to the person in your care.
NOTE: To find out how many patient complaints were registered against an HMO, call your state insurance commissioner in the phone book under State Government.