Health Maintenance Organizations

Health Insurance

SOCIAL ISSUES IN THE UNITED STATES

REASONS FOR HEALTH INSURANCE

TYPES OF PLANS IN THE UNITED STATES

Health Maintenance Organizations

Health maintenance organizations (HMOs) agree to provide whatever medical services are required in exchange for the plan participant’s monthly premium payment. HMO members generally receive excellent coverage of routine health care services, but they often face restrictions on their choices of doctors and hospitals. Services provided by HMO member physicians and facilities are covered almost in their entirety. Services provided by nonmember physicians and facilities are not covered at all except in emergencies or when specialized care is needed and the referral is authorized in advance.

The way in which an HMO is organized determines which health care providers are available to its members. A group practice association, such as the Kaiser Permanente Medical Care Program, is both an insurer and a provider of health care services. It hires health care providers as employees and builds its own hospital facilities. Members of a group practice association may arrange for any physician employed by the group to be their primary care physician—their first contact for health care. An independent practice association establishes a contractual relationship with doctors and hospitals to provide services to its members. In a group practice association and in an independent practice association, patients who require specialty care usually may obtain referrals to see specialists only within the HMO, unless the specialty care needed is not available within the group.

DISABILITY INSURANCE
OBTAINING COVERAGE
FEATURES OF HEALTH INSURANCE POLICIES
LEVEL OF COVERAGE
SPECIFIC BENEFITS
HISTORY IN THE UNITED STATES
HEALTH INSURANCE IN CANADA
HEALTH INSURANCE IN OTHER COUNTRIES

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