It’s Your Health - How to get the most out of your HMO

A 16-page, illustrated booklet that describes doctor-patient relationships, knowing what is usually covered in HMO plans, standing up for your rights, and how to handle quality-of-care issues. Includes a 17-point coverage checklist.

Note: This publication addresses HMO policies in general. To check on specific coverage for your own plan, call your HMO member services number listed on your health insurance card. (Revised 2001.)

It's Your Health - How to get the most out of your HMO

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Managed care has changed the face of medical care. In the U.S., more than half the population receives health care through managed care systems such as HMOs (health maintenance organizations).

Each HMO provides a full range of health care coverage through its network of doctors, clinics and hospitals, who work together to coordinate patient care and contain costs. The HMO uses a list of physicians and facilities, and has a fixed fee structure for all services.

Today's employers often provide health insurance through HMOs because they offer comprehensive health care at competitive rates. This shift from traditional insurance where patients are free to choose any physician began in the early 1990s and continues today.

While HMOs have been around for decades, in the past few years they have seen a tremendous jump in membership. Today, more than 80 million Americans are in HMOs, Medicare HMOs or point-of-service (POS) managed care plans. Another 70 million are covered by other forms of managed care, which include preferred provider organizations (PPOs). (POS and PPO plans give members more choices of where to receive their health care than traditional HMO plans do.)

The change has caught many people unaware. Participants in managed health care are viewed as doctors' patients and as HMO members. This means that you need to learn how managed care works, how you can be more responsible for your own medical care and how you can get the most out of being an HMO member.

Because managed care has proven to be an effective way to reduce costs, many employers offer only HMO or PPO plans. You may no longer have a choice between traditional health insurance and an HMO or PPO plan. But instead of limiting your choices, active and assertive participation in your HMO can broaden your health care options and cut your out-of-pocket medical expenses.

You & Your Doctor

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Within an HMO, the doctor you choose to be responsible for your health care is called your primary care physician. This person will be your health care advocate -- your most important link to satisfaction in the HMO.

The doctor-patient relationship is key to your health, because your primary care doctor coordinates all your medical care: routine checkups, preventive services, referrals to specialists, and hospital visits. Your doctor knows your entire medical history and what is important to you. This knowledge can be crucial to your care should you become critically ill and may reduce the chances of complications during your treatment. You and your doctor must become partners in your health care.

HMO-affiliated doctors are held to quality standards and are regularly reviewed by their medical colleagues. Having a well-qualified doctor is obviously important. But it is just as important to have a doctor you are comfortable with. Because the relationship between the member and the primary care doctor is key to providing quality health care, HMOs allow members to change primary care physicians.

You choose your doctor from a list provided by the HMO. Many people find that their own doctor is on the list. If your doctor is not affiliated with the HMO, call your plan's member services department to learn more about the doctors who are available. (To find doctors and to check their medical licenses, go to the Association of State Medical Board Executive Directors' DocFinder Web site.)

Discuss your preferences about office locations, training and education and languages spoken with the member services representative when you are looking for a physician. This will help you narrow the field of doctors to choose from.

If you decide to change doctors, you must choose among physicians in the network. Generally, the change takes 30 days to become effective. (At some HMOs, if you decide to switch after the 15th of the month, you will have to wait until the second calendar month following the change to see your new doctor.) Call your plan's member services department if you do not understand your rights and responsibilities in changing doctors.

There can be many good reasons to change your primary caredoctor. Above all, you should be comfortable with the relationship. Your doctor should answer your questions and give you complete explanations of all suggested treatment plans, therapies, shots, drugs and surgery. You should feel your doctor is concerned about your well-being, and that you are participating fully in your own health care decisions.

You may decide to change because you do not like your doctor's personality or bedside manner. The location of the doctors office may become inconvenient if you move. You may prefer a male or a female doctor, one who speaks the same language you do, or one who is open and accepting of your culture or lifestyle.

Know What Your HMO Plan Covers: Your satisfaction depends on it

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What is usually covered?

HMO coverage varies widely. Your benefits may even differ from those of other members of your HMO. This could be because your employer decided to pay for different benefits. Or, if you are an individual or a Medicare member, you may have different coverage from employer group members.

In most HMOs, all medical care must be approved by your primary care doctor. You will usually be asked to pay a fee of $5 or $15 (known as a co-payment) when you make office visits. (Not all plans require co-payments.)

HMO benefits usually include regular checkups for you and your covered family members. Many HMOs allow women to visit a network gynecologist for an annual women's health exam without the primary doctor's prior referral. Maternity care is usually fully covered.

Primary care doctors are trained in providing expert care for most conditions. If your primary care doctor discovers that you have a condition beyond her or his expertise, you will be referred to a specialist who is also affiliated with your doctor's group or your HMO. Most referrals are subject to approval by your doctor's medical group and your HMO. Many top specialists are affiliate dwith several health plans; you may be able to see a specific doctor you read about or were told about by a friend.

Hospitalization, when medically necessary, is also covered. Although there may be recommended hospital stays for certain surgeries, your doctor and medical group determine your actual length of stay and follow-up treatments.

Many HMOs feature prescription drug benefits, which cover each prescription for a low co-payment, generally $5-$15. Each HMO has its own formulary, or list of recommended medications. (Californians only: Check on which drugs your HMO covers.) Most HMOs offer a lower co-payment for members who accept generic drugs -- less expensive replacements for name-brand drugs that contain the same ingredients.

HMOs place great importance on preventive care health services designed to detect health problems early and encourage members to learn their family medical history and work with their doctor to reduce those potential risks. Members who want to lose weight or stop smoking may have access to workshops or classes (some have fees) and printed materials and videos with tips on staying healthy.

A Checklist For Coverage

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Your most important responsibility as an HMO member is to educate yourself about your plans coverage. This is important in getting the most out of your current plan or in comparing plans.

Inquire about rules and policies in the following areas:

Routine medical or preventive care

Routine medical or preventive care: refers to regular checkups, screening for disease, immunizations and office visits to treat an illness or injury. Under most plans, when you visit the doctor's office you are responsible for a co-payment, usually $5 or $10 per visit. If such co-payments apply for office visits, find out the maximum you could be liable for each year.

Pregnancy and maternity care

Pregnancy and maternity care: prenatal and post-natal office visits and all medically necessary inpatient hospital services are usually fully covered. Most plans cover the newborn's care. In most cases, new parents are required to enroll the baby for coverage within a month after the birth. This will ensure that your baby is eligible to receive ongoing pediatric or "well baby care." Check if your plan has any deductibles (out-of-pocket costs you must pay) or exclusions (items that are not covered) for maternity care.

Urgent medical care

This is a health crisis that demands immediate medical attention but does not require going to the emergency room. If you or a family member has an urgent medical situation, call your doctor's office right away. Tell the person who answers the phone that your call is urgent. If your call is not returned in 15 minutes, call again.

An emergency

An emergency is a sudden, serious and/or life-threatening illness or injury. It requires immediate attention because a delay in treatment could result in permanent damage to your health.

Most HMOs advise their members to use common sense in deciding whether a situation requires a trip to the emergency room. If you're not sure, call your doctor's office immediately. In an emergency, go to a hospital affiliated with your plan, if possible.

Most HMOs advise their members to use common sense in deciding whether a situation requires a trip to the emergency room. If you're not sure, call your doctor's office immediately. In an emergency, if you cannot see your doctor for some reason, go to the nearest hospital and seek appropriate attention.

As soon as possible within 48 hours, make sure that you -- or a family member -- contact your primary care doctor and health plan. This will help you receive the best coverage your plan provides in emergency situations and ensure that your doctor is kept up-to-date on your case and involved in decisions about your ongoing care.

Usually, if you are admitted to the hospital from the emergency room, there is no co-payment. Co-payments for outpatient emergency room treatment average about $50 if you followed the notification rules.

When you are away from home

When you are away from home, emergency care and urgent care usually are also covered. However, non-urgent care away from home may not be. Call your HMO's member services department for details before you leave on a trip. If the emergency facility requires immediate payment, get a complete statement of the services received and, if possible, a copy of the emergency room report. When you get home, call your plan's member services department to find out how to submit a claim or seek reimbursement.

Prescription drug benefits

Prescription drug benefits can vary enormously from plan to plan. Most HMOs have a formulary, or list, of drugs they will cover for a low co-payment of $5 or $20 each time a prescription is filled. These may be called open, managed or closed formularies. The open formulary offers an unrestricted choice of all government-approved prescription drugs. Opting for the unrestricted list increases the cost of your coverage. Other plans offer the choice of a cost-saving managed formulary of name-brand and generic drugs. Closed formularies may offer members only a set group of prescription drugs.

If your HMO has decided that two name-brand drugs are basically the same, it may choose to include only one of them in the formulary. But if that drug causes you significant side-effects and you are not responding as expected, your doctor may request authorization for the alternative drug. Ask if your plan features this -- called "prior authorization" -- for drugs not on the formulary. Or you can ask your doctor to write "dispense as written" on your prescription; however, you may have to pay more or cover the full cost of that medication.

Ask how many drugs are covered by your plan as well as other plans that you may be able to join. HMO formularies vary, covering from 200 to 1,000 drugs; there are about 2,000 government-approved prescription drugs available. If you are comparing plans and have need of specific medications, ask if the drugs you need are covered.


Hospitalization: usually you will share a room and your food and medical necessities will be covered. Ask about annual limits on hospital stays or any other limits on hospital stays for specific conditions. An increasing number of operations are performed on an out-patient basis, so you might be sent home to recuperate shortly after the procedure.

Referrals to specialists

Referrals to specialists -- physicians trained in a certain area of medicine or surgery -- usually must be authorized by your primary care doctor, and your doctor's medical group. However, some large plans have sped-up authorization and access to specialists in their networks. Many plans allow members to refer themselves to some network doctors for routine specialty care such as dermatology or gynecology. This is sometimes called direct access. Most HMO plans require that you wait until the referral disapproved before seeing a specialist outside the network.

Chronic illnesses

Chronic illnesses are conditions that are not expected to be cured --but may be controlled -- with treatment, such as Alzheimer's disease, asthma, arthritis, diabetes or epilepsy. While the management of such diseases (doctor visits and medications) is usually fully covered, some therapies or equipment for the condition usually are not. While HMOs cover some types of medically necessary equipment, many plans will not pay for equipment such as orthopedic shoes, air purifiers, pillows or mattresses and home testing devices recommended by doctors in the treatment of chronic disease.

Custodial care

Custodial care is not usually covered by HMOs. For example, an Alzheimer's patient may need ongoing assistance with taking medications, bathing or cooking.

Vision and hearing exams

Vision and hearing exams may be optional services in some plans.

Initial drug and alcohol addiction treatment

Initial drug and alcohol addiction treatment (detoxification) is usually covered; however, if repeated or habitual treatment becomes necessary, some HMOs may deny ongoing treatment.

Mental health care

Mental health care may be limited to acute (sudden or serious) mental illness and may preclude the treatment of chronic mental illness or behavioral problems. Outpatient therapy visits are sometimes provided for, but usually are limited to short-term therapy for a prescribed number of visits. Each visit is usually subject to a co-payment of $10-$25 or more.

Home health care

(visits by health care professionals) may or may not be covered by your plan, and may be limited to a certain number of visits. In most cases, a co-payment will apply for each visit.

Hospice care

Hospice care may or may not be covered. (Hospices are facilities or programs for dying people that focus on care rather than prolonging life with additional medical interventions.) If you are in a Medicare HMO plan, hospice benefits as covered by Medicare will be available.

Physical therapy

Physical therapy recommended by your doctor following surgery or an injury is usually covered. The therapy may be limited to a certain time period or number of visits.


Experimental, sometimes called "investigational" treatments, that have not been scientifically proven to be effective for a particular disease or condition, are usually not covered. If such a treatment is denied to a dying patient, some states require the health plan to pay for another medical opinion. Some states and plans also provide for a fast-track arbitration process, recognizing that the patient may not have long to live without the treatment. HMOs also have been known to reverse their own decisions on experimental treatments, following appeals by members when medical evidence supports a decision to cover treatment.

Stand Up For Your Rights

The managed health care industry is still young and experiencing growing pains. Some people view it as unresponsive and slow-moving. But your HMO's concern for cost efficiency makes it financially possible for your employer to provide you and your family with comprehensive health coverage.

It takes a lot of persistence and energy to get satisfaction in working with any large organization. Unless you stand up for your rights, you may end up getting lost in the system and you may receive less than the best possible care.

Be your own advocate:

It's your health at stake. Be persistent in seeking the best health care from your HMO and your physician. Don't accept the first response if it doesn't meet your needs. Ask your doctor: What are my options in terms of treatment?

Ask your plan to consider the care you feel is necessary, even if it is excluded from coverage.

Speak up if you feel you need additional treatment. It doesn't hurt to ask, and doing so may result in improved care.

Your doctor can be your best advocate.

Having checkups and following your doctor's advice will show you to be someone who is willing to take extra steps for your own health. When you need ongoing medical treatment or surgery, your relationship with your doctor will help you gain access to the most appropriate care possible.

Find a physician who knows how to work with the system.

Your doctor is your caregiver and has the right to seek exceptions to HMO rules when she or he finds it medically necessary.

Demand appropriate, necessary care.

People who know what they need are more likely to get what they want. Do research to back up arguments about your care. Clip articles about new treatments from health magazines. Search the Internet for information about your condition. Show that you are a savvy consumer who is interested in seeking out the best health care possible. If you become too ill to participate in your health care decisions, enlist a spouse, relative or friend to act as your advocate.

Don't postpone seeking help in a serious medical emergency because of fear that your HMO won't cover the cost.

Know your HMOs rules for emergency situations, but realize that it may be impossible to reach an affiliated hospital in time. Emergency rooms should not serve as a substitute for routine care, but when you are confronted with life-threatening emergencies or any serious illness or injury, seek help quickly. Worry about who will pay for it later.

How to Handle Quality-of-Care Issues

Speak up immediately when you have concerns about the quality of your care. Start by speaking with your primary care physician. If your doctor cannot provide a satisfactory answer, call your HMO's member services department. In many cases, your plan's representatives can help you get the benefit you need. Your employer's health benefits administrator may also be able to help.

If you have a complaint that cannot be easily resolved, your first step is to file an appeal with your HMO to ask that your request be reconsidered. The member services department will help you understand why your request is being denied and explain how to file an appeal. The National Association of Insurance Commissioners has a consumer guide to resolving health care insurance disputes.

If you are not satisfied with the outcome of your appeal, send a letter to the plan's medical director and the head of its member services department. Ask them to respond to you within a specified number of days, and tell them that you will seek regulatory or legal help if necessary.

If you cannot resolve a problem with the HMO, you can file a grievance with your state's HMO regulatory agency. Your HMO's member services department will provide you with that agency's name and phone number. When you call the regulator, ask how to file a grievance about an unsatisfactory treatment decision by your HMO. The National Association of Insurance Commissioners web site has a list of all health state departments of insurance.

You may be able to obtain valuable information about treatment options from non-profit health advocacy groups, such as the American Cancer Society or the American Lung Association and Internet web sites. They often have data on the effectiveness of new treatments and this information may help you decide whether to file an appeal or a grievance.

In response to consumer concerns, many states now require HMOs and health plans to provide consumers with an independent external review (IER) process. The review, free to individuals, enlists physicians and other medical professionals who are not affiliated with the health plan in reviewing decisions related to medically necessary care and access to experimental treatments or medications. The health plan must abide by the IER decision-but individuals retain the right to appeal the decision. If your state requires IER, your health plan must provide you with information about the process in its member handbooks and through its member services. (For more information on your state's law, see A Consumer Guide to Handling Disputes with Your Private or Employer Health Plan.)

As a last resort, consider contacting a lawyer. Sometimes just a letter from an attorney will result in action. (Search for a lawyer at the National Association of Consumer Advocates' Web site.) If you cannot afford a lawyer, call a legal aid organization in your area. Also, many news organizations have consumer advocacy reporters and journalists who may be interested in consumer concerns related to health care.

HMO membership contracts almost always require binding arbitration to settle most disputes. This means your case will be considered and ruled on by a panel of qualified individuals instead of being heard in a court of law. If your claim is subject to binding arbitration, you waive your right to a court or jury trial.

You should not begin the arbitration process without the advice of an attorney. Most HMOs require you to file a demand for arbitration and pay a fee to begin the arbitration process. You may also be liable for arbitration costs, which can run into thousands of dollars. But none of the requirements or the potential cost should dissuade you from pursuing a valid claim. (Some HMOs have provisions for waiving some of the costs of arbitration in cases of extreme hardship.)

Get a grip on your HMO coverage

Read your disclosure form.

This document, sometimes called evidence of coverage, is your road map of policies and rules. Coverage can vary widely among HMOs.

Keep your membership card handy.

You will need the card when you visit your doctor, have medical tests, purchase prescription drugs, or access emergency care. It tells how to reach your doctor and the HMO responsible for your health care, and shows that you are insured.

Know the phone number for member services.

This phone number can usually be found on your membership card. HMO representatives are available to explain and answer questions about your coverage. If your doctor cannot resolve a concern, contact member services.

This publication is funded by PacifiCare® Health Systems

Published / Reviewed Date

Published: June 01, 2001

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