How to Choose an HMO

Quality of Medical Care

An HMO gives you good quality medical care if:

  • You get the right care at the right time.
  • Medical problems are found early when they can be treated best.
  • You get the treatment that has been proven to work.
  • Doctors listen to your concerns and explain your treatment choices clearly.

An HMO gives you poor quality medical care if:

  • You cannot get the treatment you need.
  • Diseases like cancer are not found early when you have a better chance of recovery.
  • The HMO delays care and a minor problem becomes a big one.
  • You are not taught what you need to do to stay healthy.

Quality of Service

An HMO gives you good quality of service if:

  • You get care right away when you are ill or have an urgent need
  • You get answers to your questions quickly and courteously.
  • You and each family member has a personal doctor whom you trust and who listens to your concerns.
  • The materials your HMO sends you clearly explain what services it pays for and what rules you have to follow to get services.

An HMO gives you poor quality service if:

  • It is hard to find a personal doctor you like.
  • You are surprised to get a bill for medical services that you thought was paid for by the HMO.
  • It is difficult and takes a lot of time to see a specialist or get the care you need.

Choosing a Doctor

Most HMOs require members to choose a personal doctor from a list of doctors who work with the HMO. This is your main doctor. These doctors are called Primary Care Physicians, or PCPs. They are trained in one of the four primary care specialties: pediatrics (children’s medicine), family medicine, obstetrics and gynecology (women’s medicine), or internal medicine.

PCPs provide most of your routine care. This includes preventive services, like checkups, and care for acute and chronic conditions and psychosocial issues. PCPs also oversee all of the health care services you get. They refer you for tests and care from specialists (doctors who have training in a special field of medicine, such as the heart or cancer treatment).

When you choose a doctor, you also choose a medical group. For example, if your PCP refers you to a specialist, the specialist will be in the same medical group as your PCP. To learn more about medical groups, click on “How to select a medical group.”

A good HMO checks the quality of its doctors. Ask the HMO what steps it takes to make sure that its doctors give good care and service.

Can I Keep My Doctor if I Change HMOs?

If you are changing HMOs and you want to keep your personal doctor, call your new HMO. They will tell you if your current doctor is part of their network. If your doctor does not belong to that HMO, you would have to change doctors or pay all the costs for care from your doctor.

Many doctors belong to more than one HMO. If your doctor is not part of an HMO that you are considering, see if you could continue seeing your doctor by joining a different HMO.

What Medical Services Do HMOs Cover?

HMOs must provide many basic services, and certain other services. However, HMOs must provide these services only when they are medically necessary.

HMOs must cover at least the following basic health care services:

  • Doctor and hospital services, including inpatient services—when you have to stay overnight in the hospital — and outpatient services, such as minor surgeries done in an office or clinic
  • Laboratory tests to diagnose problems, like blood tests, sexually transmitted infection (STI) tests, pregnancy tests and some cancer screening tests
  • Diagnostic services, like x-rays and mammograms
  • Services to treat health problems, like chemotherapy for cancer
  • Preventive care, like vaccinations and checkups
  • Emergency and urgent care—even if you are outside your health plan’s service area
  • Diabetes services and supplies
  • Mental health care for some serious problems
  • Some rehabilitation therapy, such as physical, occupational and speech therapy
  • Some home health or nursing home care after a hospital stay
  • Some hospice care (care for people who are dying)

What About Prescription Drugs and Other Services?

Most HMOs cover some prescription drugs. Each HMO has a list of drugs that it will pay for. This is called the formulary. Each HMO has its own formulary with different drugs.

Most HMOs charge a co-pay for each prescription drug. The co-pay often is higher if you get the brand name form of the drug when a generic form is available. The co-pay also may be higher for drugs that cost more. If you take prescription drugs, find out if the HMO pays for the prescription drugs you take. And find out what your co-pay will be. If your prescription drugs are not covered, ask your doctor if there are other drugs you can take.

Although all HMOs must cover basic health care services, other services vary from HMO to HMO. For example, some HMOs offer special programs for members to help them lose weight, get exercise, or stop smoking. These same HMOs may cover fewer services for routine checkups or mental health care. Find out what services the HMO offers. Make sure that the services you need most are covered. If you have special health care needs, like medical equipment or supplies, find out how much the HMO will pay for what you need. You also should find out how much of the cost you will have to pay.

Costs to You

Costs can differ a lot from HMO to HMO. All HMOs charge a monthly premium for medical services. HMOs also charge members a co-payment (co-pay) or co-insurance each time they get health care services. A co-pay is a fixed fee for a specific service such as $20.00 for an office visit. Co-insurance is a percentage of the cost of the service, such as 20 percent of the cost of an office visit. One HMO may have a higher co-pay or co-insurance for the same service than another HMO.

In addition to your share of the monthly premium amount, your costs will depend on the services you use and amount you pay each time you get care. And, your costs may include a yearly deductible. The deductible is the amount a person pays each year before the HMO begins to pay any part of the cost of services.

Rules and Restrictions

HMOs often have rules about the steps you must take to get care. For example, you may need to get a referral or an approval to see a specialist or to get certain tests and treatments. This means that your doctor has to ask for the service and/or the HMO has to agree that it will pay for it. If you do not follow the rules, you may have to pay the cost yourself.

When you travel, most HMOs only pay for care if it is an emergency or if you need urgent care. Check your HMO coverage rules for care when you travel.

Make sure you understand all the rules and restrictions before you choose an HMO.