Evaluating an HMO: A Checklist 

Juliet D'cruz

Updated on:

HMOs are sometimes great alternatives to traditional health insurance plans– but not always. Of course there are pros and cons you will have to weigh when deciding whether or not you want to go with an HMO or traditional health insurance. And like traditional health insurance, not every HMO is created equal. Fortunately, Brian Gabriel, Lake Worth criminal defense lawyer and insurance expert has written a guide for the readers to use when evaluating and HMO

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  1. In your contract, study the services your HMO is obligated to cover.
    Find out if the treatments you foresee needing–obstetrical services, special medications, psychotherapy, in-home care–are covered. If you have a pre-existing condition–and some 81 million Americans do–know when and if coverage for it kicks in: some plans require that you be enrolled for at least a year. Remember, what is accepted treatment to some in the medical community may not be permissible under your plan. Also take a close look at any benefit caps. They may look high, but so are costs once you are hospitalized.
  2. Access to the physician.
    Be sure there are doctors you like and a covered hospital and pharmacy in your neighborhood. It also helps if the plan has a 24-hour-a-day service line.
  3. Capitation and incentives.
    If the doctors receive a set fee per patient–or a bonus for minimizing costs–you could get shortchanged on necessary tests or referrals. Keep in mind that HMOs are businesses and are run like businesses. Any plan in which doctors cannot discuss treatment not covered by their company can be hazardous to your health in the event of a serious illness. Some states are making it illegal for an HMO contract to contain gag clauses. California does not.
  4. Check out the HMO with the National Committee for Quality Assurance.
    A copy of their free Accreditation Status List is available by calling (202) 955-3515. Then read Quality Ratings – Another view of the NCQA.
  5. Find out how many of the HMO’s doctors are board-certified.
    According to an industry association, 85% of HMO doctors meet this standard. If your HMO doesn’t, choose another one.
  6. Learn the HMO’s referral procedures, the reputation of the hospital you’d go to if ill, and the drugs provided in the HMO’s formulary.
    The time to find out if your prescription medications are covered is before you enroll.
  7. Determine the rules about seeing doctors outside the HMO’s panel of physicians.
    In some plans you cannot switch doctors or see a specialist without authorization. This can delay or deny care.
  8. Consider a point-of-service, or open-ended, type of HMO.
    They are more expensive than standard HMO plans, but allow members greater flexibility in seeking care from outside specialists.
  9. Ask to see the HMO’s most recent member-evaluation survey and talk with HMO members.
  10. Make sure the HMO doctors you want are accepting new patients.
    Some groups recruit well-known physicians to lure new members; then the enrollees discover that the doctors aren’t available.
  11. Find out the HMO’s physician-turnover rate.
    Be wary if it runs 20% or more a year. This may indicate low pay to doctors or refusal to permit referrals or procedures requested by doctors.

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