Basic
and Supplemental Services
The emphasis of HMOs is prevention, because the benefits offered are
broader than those provided by commercial insurers or the Blues. HMO
benefits are not limited to treatment resulting from illness or injury
because
they also include preventive health care measures such as routine physical
examinations.
HMOs are required to provide for the following basic health care
services:
- Inpatient hospital and physician services for a period of
at least 90 days per
calendar year for treatment of illness or injury. If inpatient treatment
is
for mental, emotional, or nervous disorders, including alcohol and
drug
rehabilitation and treatment, services may be limited to 30 days
per calendar
year. Treatment for alcohol and drug rehabilitation and treatment
may be restricted to a 90-day lifetime limit. A partial list of the
hospital
services provided include room and board; maternity care; general
nursing
care; use of operating room and facilities; use of intensive care
unit;
x-rays, laboratory, and other diagnostic tests; drugs, medications,
and
anesthesia; physical, radiation, and inhalation therapy.
- Outpatient medical services when prescribed or supervised
by a physician
and rendered in a non-hospital–based health care facility (for
example,
physician’s office, member’s home, and so forth). Outpatient
medical
services include diagnostic services, treatment services, short
term physical
therapy and rehabilitation services, laboratory and x-ray services,
and
outpatient surgery.
- Preventive health services with the goal of protection
against and early
detection and minimization of the ill effects and causes of disease
or disability.
Specifically, this will include well-child care from birth, eye
and ear examinations for children age 17 and under, periodic health
evaluations, and immunizations.
- In and out of area emergency services, including medically
necessary ambulance
services, available on an inpatient or an outpatient basis 24 hours
per day, 7 days per week.
Many HMOs may but are not required to provide one or more of the
following
supplemental health care services:
- Prescription drugs
- Nursing services
- Vision care
- Long-term care
- Dental care
- Mental heath care
- Home health care
- Substance abuse services
Consumers who want supplemental services may purchase them from the
HMO only as an adjunct to the basic health care services the HMO
offers.
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