HMO Quality Assurance
Because HMOs provide service benefits rather than reimbursement benefits,
they are required to follow guidelines prescribed by the insurance
department
to assure quality service to members. These guidelines specify the
requirements for reasonable hours of operation and after-hours emergency
health care and standards to ensure that sufficient personnel will
be available
to attend to members’ needs. The guidelines also require adequate
arrangements
to provide inpatient hospital services for basic health care and a
requirement that the services of specialists be provided as a basic
health care
service.
Open-Ended Plans
An open-ended HMO (also known as a leaky HMO and point-of-service
HMO)
is a hybrid arrangement whereby participants may use non-HMO providers
at any time and receive indemnity benefits that are subject to higher
deductible and coinsurance amounts. The out-of-pocket cost to the
participant
(and probably the employer, too) is higher, but the arrangement allows
participants to remain in control in choosing a health care provider.
Open-Access HMOs
Dissatisfaction with the gatekeeper mechanism, delays in receiving
care, and
problems in obtaining referrals have led many health plans to offer
open
access. An open-access HMO allows members to receive care from network
specialists without first going through a primary care physician
(gatekeeper)
and receiving a referral. Alternatively, a point-of-service (POS)
plan allows
members to seek the care of a specialist outside the HMO provider
network.
Because the plan does not control the outside provider, POS plans
tend to be
more expensive than open-access HMOs.
