The Basics of Health Maintenance Organization – HMO Plans

Medical team in discussion in hospital corridor

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As a healthcare consumer, you've no doubt heard the term HMO before. In fact, this is the most popular of all health care plan models in the market. Where do HMO's come from? Here's some history on this type of employee benefit. In 1973, The Health Maintenance Organization Act amended the previous Public Health Service Act of 1944 and effectively transformed the way health benefits were to be managed in America.

An Overview of HMO Plans

An HMO is not really that complex. Under current US legal code, an HMO is defined as a public or private entity that meets both of the following requirements:

  1. Provides basic and supplemental health services to its members
  2. Is organized and operated in a state-approved manner

Therefore, an HMO is an organization that has the sole purpose of providing equal access to health care services in exchange for members agreeing to certain terms. In most cases, this is an agreement to remain within a covered network of providers who have pre-negotiated for lower-cost services, while still retaining the quality of care.

These providers must meet high standards in order to join the network, and they must maintain excellent care ratings, so it's a win-win for consumers. In many cases, the HMO supports preventative wellness care, which is what health care providers advocate for. This works well with corporate wellness programs and recommended routine medical care for certain demographics of the population.

All HMOs undergo close scrutiny by many government organizations, including each State Department of Health in which they operate. HMOs came under fire in the late 1990s when it was discovered plan members were not getting the timely response and care they deserved. Since then, HMO management has improved thanks to electronic data management which streamlines data management and enrollment processes.

The Benefits of HMO Plans

HMO's are still one of the more popular health management options that employers offer, for a number of reasons.

  • They are relatively easy to manage because of flat-rate premiums for plan member types.
  • Claims are less worrisome for plan members because they know how much their portion is, including office co-pays.
  • HMOs are often cheaper health care plans for employers and members over the life of the plans.
  • The quality of the doctors and health care centers are carefully monitored to the highest of standards, so plan members know they are getting the best possible care.
  • An HMO approval process controls expensive medical claims before they take place, and this also protects consumers from fraud.

Trends in the Health Care Market HMO Use

According to the experts in health care, the trend away from traditional fee-for-service health care plans has been steady over the last two decades. The US Department of Labor advises that fee-for-service plans accounted for 96% of health care plans offered by medium and large public employers in 1984 and 20 years later they account for less than 15% of employer-provided health insurance. Managed health care policies continue to replace former cash-for-service health programs.

Many companies offer at least three-tier employee benefits plans, with one or more as part of an HMO network. It is a cost-effective way of managing health care insurance and maintaining the quality of care. Health maintenance organization plans continue to be a strong component of care in the health insurance market today.