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Deciding on an HMO

Are you thinking about joining an HMO (health maintenance organization)? As an HMO member, you don't pay any hospital or doctor bills. Instead, the HMO pays your bills. What you pay is a monthly membership fee and relatively small co-payments for most services. In Maryland, HMO members who follow proper procedures cannot be billed for covered services, even if the provider doesnot have a contract with the HMO.

However, you must see only HMO-affiliated doctors and go only to HMO-affiliated hospitals, except in emergencies. And you may not always be able to see thesame doctor each time you have an appointment.

Some consumers contacting the Consumer Protection Division are very happy with their HMO coverage. Others have been disappointed with restrictions on coverage, waits for appointments and difficulty getting referrals to specialists or authorization for hospitalization.

If you're thinking about joining an HMO, here are some guidelines to help you.

Is an HMO for You?

As an HMO member, you must be willing to allow health care professionals within the HMO make certain decisions for you that you previously made yourself, such as the decision to go to the hospital or see a specialist. Say, for example, you've seen a specialist for a chronic health problem. When you join an HMO, you may not be able to continue seeing that same specialist. Your HMO doctor may determine that a specialist's care isn't warranted in your case. Or if that specialist is not part of the HMO network, you'll be assigned to another specialist.

In most cases, you must select a primary care doctor from the HMO's list, and this doctor must be contacted each time you need services. Under some plans, an OB-GYN may be a woman's primary care physician if she chooses; other plans require a specialist's referral to see an OB-GYN.

As an HMO member, you have the responsibility of knowing and following the HMO's rules for such procedures as requesting referrals to specialists, getting emergency care, and having problems resolved if you're unhappy with your care. You'll pay a penalty if you go outside the HMO network, so you must make sure your HMO's procedures are known to those who may be called upon in emergencies - your spouse, your son's babysitter, your daughter's sports coach.

Like everything else, HMOs vary in quality. Find out as much as you can before you make a decision to join. Talk to co-workers and your personnel benefits manager about HMO options available. If you have young children, talk with other parents who joined HMOs. Call the HMO customer service line to see how long a typical wait for service would be.

Compare and Evaluate Programs

Once you've decided to join an HMO, you need to find the best HMO for you. Do this by visiting the primary care site, reading the HMO's patient information materials, and asking questions.

1. Are the hours and location convenient? Are lab tests done in a convenient location? Is parking available? Is the facility clean? How long does it take to schedule a non-emergency visit or routine check-up?

2. Ask patients in the waiting room if they're satisfied with the HMO. What is the attitude of the staff? How long have the doctors been with the plan?

3. Ask the HMO for a list of hospitals and specialists affiliated with the primary care site you'll be using. Some consumers are disappointed to find their primary care site may not have a referral contract with every specialist listed in the HMO's directory. What are the referral procedures to specialists and hospitals?

4. On your visits, will you most often see a doctor, nurse practitioner or physician's assistant? Are the doctors board certified, meaning they've passed certain exams for competency in their specialty?

5. Can you change your primary care doctor if you're unhappy?

6. Think about services you're likely to need. Are any listed in the "exclusions" section of the description of benefits?

7. What is the procedure for getting second opinions?

8. What is the policy on emergencies? Suppose you're out-of-town when the emergency occurs?

9. Are there out-of-pocket co-payment limits?

10. Compare prescription drug coverage and limitations.

  • Are your current medications covered?
  • Are certain brands preferred over others?
  • What pharmacies must you go to? Are they convenient?
  • What are the co-payments? Do they change based on the drugs?
  • How frequently must you renew your prescription for a drug you take long-term? (A single co-payment for a 6-month supply of a drug is cheaper than 6 co-payments for 30-day supplies.)

11. What medical equipment and supplies are covered and under what circumstances?

12. Compare differences in HMO coverage for drug and alcohol treatment, physical therapy, mental health services, non-routine dental and vision care, hearing aids, experimental surgery and access to alternative providers, such as chiropractors.

13. What health education and wellness programs are provided?

Selecting an HMO requires the same skills you use in making other choices in the marketplace: understanding your needs, gathering information and calmly making your decision. If you have questions or concerns about HMOs, contact the Consumer Protection Division's Health Education and Advocacy Unit at (410) 528-1840.

For a comprehensive report on HMOs operating in Maryland, visit the Maryland Health Care Commission's Web site at www.mhcc.state.md.us.


Maryland Attorney General's Consumer Protection Division
Consumer hotline: (410) 528-8662 or 1 (888) 743-0023 toll-free


Attorney General of Maryland 1 (888) 743-0023 toll-free / TDD: (410) 576-6372
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