According to the Hospitals and Health Networks, the biggest HMO health insurance companies include Kaiser Foundation Health Plans, PacifiCare, Health Net, Oxford Health Plans and Keystone Blue Health Plan. Other names you may recognize include Aetna U.S. Healthcare, United Healthcare, Blue Cross Blue Shield and Humana Health Plan. The most popular areas for these HMOs are states like California, New York, Pennsylvania and Illinois.
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Tracking HMO numbers is difficult because companies are often organized by region. For example, Kaiser Foundation Health Plan has 2,722,738 members in their Northern California plan and 2,591,555 in their Southern California plan. A health insurance company may operate in a single state or region or they may operate nationwide.
What is an HMO?
HMO, or health maintenance organization, is a type of health insurance that offers benefits to its members while trying to keep the costs down by negotiating special group pricing with participating doctors and medical facilities. Doctors are paid a bonus by the company for the amount of HMO patients they see. HMOs usually require their members to pay a copayment for basic services and their care is managed through a single physician.
HMO health insurance is popular because it tends to save participants a lot of money. The downside of HMOs is that participants need to choose doctors within a network and they need referrals for many procedures, even if the provider is in the network.
What is the difference between an HMO and a PPO?
Two of the most common types of health insurance are HMOs and PPOs. Both are managed care plans and both create a network by negotiating special pricing with a group of doctors and medical facilities. There are, however, a few major differences.
In an HMO, each participant must have a primary care physician who will basically coordinate care for that patient. In order to have a test, specialist visit or treatment covered by the insurance, an HMO participant will usually need to have their primary care physician give them a referral. A primary care physician could be a family physician, an internal medicine specialist or even a gynecologist in some situations.
For a PPO, or preferred provider organization, seeing any physician or getting any covered treatment within the network should cost only a copayment and a deductible. The primary care physician does not necessarily have to refer you to see a specialist. If you choose to receive health care out of the network, the insurance will usually still cover it, but at a lesser amount than in network, meaning that you will pay more out of your own pocket than you would for in-network treatment.
A PPO generally costs more than an HMO. A PPO gives you more choices and flexibility, but you will pay for it. PPO premiums and copayments are usually higher than those of an HMO. A PPO deductible can be up to $2,000 while an HMO often has no health insurance deductible .
Where an HMO can end up costing you more than a PPO is if you find yourself needing a lot of out-of-network treatment. If you travel in an area where there aren’t any doctors or facilities in your network and/or you can’t get a referral from your primary care physician, you could rack up uncovered medical expenses very quickly. With a PPO, those out-of-network expenses would be at least partially covered.
Does Medicare offer an HMO plan?
Medicare Advantage, also known as Medicare Part C, is like the Medicare version of an HMO. This is provided not by the government, but by private insurance companies approved by Medicare. The private company is mainly paid by the government, but the participant may need to pay an additional premium or copayment.
Medicare has a comparison chart that shows the differences between the different Medicare options. It is important to note that using the Medicare Advantage plan makes it impossible to use a Medicare supplement health insurance.
Who regulates HMOs?
HMOs are regulated by state agencies rather than the federal government. Some states have agencies dedicated specifically to HMOs, but many have agencies that oversee health insurance companies in general. If you ever have a problem with an HMO or another insurance company, you should first try to resolve your issue directly with the company. If that doesn’t work you should go to the agency that oversees HMOs or insurance companies in the state in which you applied for the insurance.
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