Health Maintenance Organizations (HMOs or Managed Care)
Membership in a Health Maintenance Organization (HMO) requires plan members to obtain their health care services from doctors and hospitals affiliated with the HMO. It is common practice in HMOs for the plan member to choose a primary care physician who treats and directs health care decisions and who coordinates referrals to specialties within the HMO network. The doctors and hospital personnel may be employees of the HMO or contracted providers.
Since HMOs operate in restricted geographic regions, this may limit coverage for plan members if medical treatment is obtained outside the HMO network or coverage area. California HMOs are required to cover medically necessary emergency services even when outside of their coverage area. The intent of managed care products is to create less costly delivery of health care services while maintaining quality health care by specifying provider choice.
What is a HMO?
HMO is short for “Health Maintenance Organization”. Unlike a PPO network of independent care providers, HMOs are care providers within fixed facilities, and benefits are designed to cover services obtained at the HMOs medical centers or facilities and supplied by HMO physicians and personnel.
Your HMO coverage plans must specify how and under what circumstances services may be obtained from non-HMO providers, and this information is crucial to determining the value of the HMO plan under your particular circumstances. At ZIS, we can assist you in choosing the best HMO plans available in your area, with the benefits that fit your needs. We can help you make wise medical coverage choices.
Important Points to Remember About HMO Insurance
- You must obtain health care services from HMO providers, except in certain emergency situations.
- Your choice of primary care physician is important because he/she directs your care.
- Also, your primary care physician often coordinates referrals to specialties within the HMO.
- Your options may be limited by the geographic restrictions of the HMO network.
- You may be charged a small copayment each time you utilize an HMO covered service.
- You can seek assistance from the DMHC on all HMO and managed care questions.
California HMO
All HMOs in California are regulated by the Department of Managed Health Care (DMHC). If you have a complaint with an HMO, contact the member services department of your HMO. HMOs are required to have an internal complaint/grievance process in place.
Contact ZIS for Advice
Contact ZIS support team for help and advice on choosing the best health insurance plan that fits your needs and to get quality service and honest advice.
- Contact us toll free at 1- 877- 990- 3808
- Or e-mail us with your questions and request at zis@zisinsurance.com
To Contact Department of Managed Health Care (DMHC)
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
Phone: 888-466-2219
Web site: www.dmhc.ca.gov
