Important
Features Of HMOs
Some features of HMOs are unique and do not apply to traditional
forms of
reimbursement insurance.
Gatekeeper System
HMOs often have a gatekeeper system under which the member must select
a
primary care physician (PCP), who in turn provides or authorizes
all care for
the particular member. Any referrals, such as to specialists, must
be made and
authorized by the PCP. In emergency situations, the member’s
needs are covered,
but generally the individual must notify the PCP as soon as possible
if
it wasn’t possible to do so when the emergency arose.
Twenty-Four Hour Access
As a rule, members have 24-hour access to the HMO. Telephones are
answered and referrals and authorizations are made 24 hours a day,
7 days a
week. Nursing and medical staff, including PCPs, must be willing
to respond
during nonbusiness hours as well.
Open Enrollment
The term open enrollment can mean one of the following:
- In employer-sponsored group plans, a time period each year
when
employees may choose to enroll or remain enrolled in the HMO or
to change health plans
- A time period each year when an HMO must advertise availability
to the
general public on an individual basis
In the first case, open enrollment allows employees who have not
yet joined
the HMO to do so if they wish. Those who are already HMO subscribers
may at this time also choose to continue in the HMO or to change
plans if
another health care plan is available.
In the second case, open enrollment may be required by state law,
permitting
all who apply to join. During this period, which usually lasts 30
days, the
HMO generally may not reject any applicant for health reasons. However,
some laws permit the HMO to refuse enrollment to people who are hospi
talized during the enrollment period or who have chronic illnesses
or permanent
injuries.
Nondiscrimination
When HMO coverage is offered to a group, the HMO may not refuse to
cover an individual member of the group because of adverse preexisting
health conditions, such as a history of heart trouble that predates
enrollment
in the HMO. This is different from traditional insurers, which generally
have the option of refusing to cover certain group members and of
excluding
preexisting health conditions.
