HMO Pros & Cons | Snohomish County, WA (2024)

FAQs

HMO Pros & Cons | Snohomish County, WA? ›

On major disadvantage is that it is difficult to get any specialized care because the members must get a referral first. Any kind of care that is sought that is not a referral or an emergency is not covered.

On major disadvantage is that it is difficult to get any specialized care because the members must get a referral first. Any kind of care that is sought that is not a referral or an emergency is not covered.

Because of the agreed-upon payment level, an HMO usually offers lower monthly premiums than other types of insurance plans. They also tend to have lower copays and coinsurance, which helps make them more affordable.

Doctors often prefer PPOs because they offer greater reimbursem*nt rates compared to HMOs and have less administrative paperwork. Is a PPO a good thing? For many, a PPO's flexibility and coverage make it a favorable choice, but it comes with higher premiums.

The costs of an HMO plan

HMO plans coordinate care for a set payment rate. That means you typically have: Lower monthly premiums (the amount taken out of your paycheck) Lower deductibles (the amount you need to pay before your plan begins contributing to your medical bills)

HMO plans might involve more bureaucracy and can limit doctors' ability to practice medicine as they see fit due to stricter guidelines on treatment protocols. So just as with patients, providers who prefer a greater degree of flexibility tend to prefer PPO plans.

Cons Explained

No specialist visits without a referral: You'll need referrals for any specialists if you want your HMO to pay for those visits. If you need to visit a rheumatologist or a dermatologist, for example, your PCP must make a referral before you can see one for the plan to pay for your visit.

Except in cases of emergency, out-of-network care is typically not covered. Furthermore, the HMO has the right to refuse payment if the requested service or treatment. If the procedure is considered experimental, cosmetic, or not on the approved list of covered procedures, it may be denied.

HMO Basics

In most HMOs you must select a main doctor, called a primary care physician, or PCP. This doctor gives you most of your care and refers you for other services when you need them. Usually, you must see this doctor first before you can see a specialist. Your primary care doctor must be in the HMO's network.

The Primary Disadvantage of an HMO Plan

HMO plans do not give you the flexibility of the PPO plans that many people have become accustomed to using. You are limited to a smaller (typically local) network of providers – usually a particular hospital system.

Should I avoid HMO? ›

HMO plans tend to be more affordable with lower monthly premiums and lower out-of-pocket costs — unless you see an out-of-network provider. You will also likely not have to file a claim, since you are seeing physicians in your network and your insurance provider will work with your healthcare providers directly.

In some cases, you will have to pay a doctor for services directly and then file a claim to get reimbursed. This is most common when you seek services from out-of-network providers. Generally speaking, an HMO might make sense if lower costs are most important and if you don't mind using a PCP to manage your care.

Cheaper health insurance rates: HMO plans are usually a lower-cost alternative to PPOs. The average HMO rate is $427 monthly for an Affordable Care Act (ACA) plan for someone who is 30 years old. That's compared to $512 monthly for a PPO plan for the same person.

For you to receive covered care, you must see professionals within this group. This lack of flexibility is a disadvantage of HMO insurance plans because, without easily accessible in-network providers, covered care will also be inaccessible.

Advantages and disadvantages of HMO plans

You pay lower monthly premiums and usually lower out-of-pocket costs, including prescriptions. When you get in-network care, you have fewer claims to file.

Sadly, many HMOs are run by either incompetent or corrupt bureaucracies, thereby compromising necessary patient care in lieu of their bottom-line. That said, some HMOs are better than others, and both patients and doctors must do their due diligence to determine whether or not to participate.