Learn the Advantages and Disadvantages of Joining an HMO

2. To acquire specialist care, you must go through several levels of service.

When you have an HMO for your healthcare coverage, the only option to see a medical specialist is to get a recommendation from your primary care physician. If your primary care physician disagrees with the judgment that seeing a specialist is important for your health, you will not be granted financial authorization to make an appointment. You could still go, but you’d have to pay full price for the pleasure.

If you do receive a recommendation, you must go to an in-network provider to receive the healthcare services you require. For some medical conditions, your network may only have one specialist. This would mean that your options for getting relief would be much more limited.

3. If you join an HMO from a different plan, you may be required to change doctors.

If you already have health insurance and are considering joining an HMO to save money, you should be prepared to quit your existing doctor. Any medical practitioner who is not a member of the HMO will charge you the full amount for the services provided at each appointment. If you have an established relationship with a doctor that you do not want to lose, you may find that a Preferred Provider Organization (PPO) is a better alternative for you.

4. You may have no other choice except to join an HMO.

In the United States, most HMOs are made available through the healthcare insurance coverage that employers provide. Because of its cost-cutting features, this plan may be the only option available to you if you work for a small business. If you require a lot of special treatment and there isn’t much in-network help for your disease, this might be an expensive predicament.

If an HMO is your sole option, speak with your HR person to see if there are any other solutions for your condition. There could be certain particular provisions or options that apply in your case.

5. The HMO must occasionally authorize operations or tests.

Assume you go to the doctor because your knee is bothering you. You slipped in the driveway about a month ago, and the pain is worsening rather than improving. After seeing your primary care provider, it is recommended that you get an MRI of the joint to check whether there is any damage that necessitates a more significant intervention. Some HMOs require the medical provider to obtain financial authorization for the service before the imaging can be performed. If the insurer does not permit it, you are compelled to pay for it or go without, putting you in an awkward position.

You can always appeal an HMO decision if it limits what you or your doctor consider to be an essential service, but there is no guarantee that the conclusion will be favorable in any case.