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HMO - Health Maintenance Organization

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HMO — Health Maintenance Organization
This is a broad term that, in general, refers to any organized plan other than a traditional health insurance company that provides for your health care. Some plans are very tightly structured so that all care is provided by the HMO's employees in the HMO's hospitals or clinics, while other plans are cooperative agreements among independent doctors, hospitals and other health care providers.

The following question and answers may not apply to you or your company. Please verify all information directly with your health insurance provider PRIOR to purchasing health insurance.

What Is A Physician Group and Why Do They Have Financial Problems?
A physician group is a private business that contracts with HMOs and other health insurers to provide physician services. Like any private business, some are successful and some aren't. While the Department is working to ensure better financial stability in the HMO industry, be assured that your health rights are secure, no matter what happens to your doctor's physician group.

While your doctor may belong to a physician group, your health care is covered by your HMO, not your physician. That means your HMO is required to provide you with the same level of health care for the duration of your contract, no matter who your physician is or what happens to his or her physician group.

If My Doctor's Physician Group Goes Out of Business, Does That Mean I Lose My Health Care Coverage?
NO! As long you pay your premiums and co-payments, you're always entitled the same level of care, treatment, preventive screenings and pharmaceuticals for the duration of your contract. In fact, that's the law and your State Insurance Department will fight to enforce it. (This information may not apply to all states. Call your Insurance Department to verify.)

If My Doctor's Physician Group Goes Out of Business, Will I Have To Change Physicians?
If you are being treated for an acute condition, a serious chronic condition, are in the second or third trimester of a pregnancy or are hospitalized, the Department of Managed Health Care requires your HMO to provide you with access to your current treating doctor for a certain amount of time, no matter what happens to his or her physician group.

The Department will always fight to find ways for HMOs to keep you with your current physician. If your HMO has to change your primary care physician, the Department will usually require your HMO to provide one within 15 miles or 30 minutes of your home. Again, that's the law and we'll enforce it.

Who Can I Go To For Help or Information?
First, start with your HMO. Your State Insurance Department has resources to assist consumers in complaints and questions.

If My Doctor Sends Me A Bill For Services, Should I Pay It?
NO! If you are in an HMO, your physician should never send you bills for services provided as a benefit. If your physician sends you a bill for services, contact the HMO to verify the bill. Explain in full the situation. If the problem does not get resolved contact your state Insurance Department.