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HMO Policies

An HMO is a Health Maintenance Organization. They provide coverage through the doctors, hospitals and other health care providers that they have a contract with. With an HMO, the insured must select a primary care physician who acts as a “gatekeeper” for medical services. Usually a primary care provider is an internist, family doctor, general practitioner or pediatrician. The primary care physician is the first stop for medical needs. If the physician thinks that the insured needs to see a specialist, the physician must authorize a referral to the specialist and file it with the insurer. Emergency medical care does not need a
referral from the primary care physician. Many HMO plans allow women to choose an OB/GYN in addition to their primary care physician, and they can see the OB/GYN without a referral. Like a PPO, an HMO has a utilization review. This is to review services provided and make sure that patients are not being given treatments they don’t need or not being given treatments they do need. It is a sort of double check of the treatments doctors are giving. Usually HMOs provide preventative care for a reduced price or for free to keep members from getting a condition that could have been prevented. Such services are physicals, child well care visits, immunizations, or mammograms.