Health Maintenance Organization HMO Chapter 46 Employee Benefit

Health Maintenance Organization (HMO) Chapter 46 Employee Benefit & Retirement Planning What is it? An organization of physicians or other health care professionals that provides a broad and nearly complete range of health care services on prepaid basis An alternative to traditional health insurance Copyright 2009, The National Underwriter Company 1

Health Maintenance Organization (HMO) Chapter 46 Employee Benefit & Retirement Planning When is it indicated? • When desire alternative to traditional health insurance • Have younger employees with dependents – HMO covers all medical expenses with relatively small copays per visit Copyright 2009, The National Underwriter Company 2

Health Maintenance Organization (HMO) Chapter 46 Employee Benefit & Retirement Planning Advantages 1. HMOs typically cover more health care services than traditional health insurance, with fewer deductibles and lower co-payments 2. HMOs focus on preventive medicine, can control overall costs better than plans that pay only when employee hospitalized or sick Copyright 2009, The National Underwriter Company 3

Health Maintenance Organization (HMO) Chapter 46 Employee Benefit & Retirement Planning Disadvantages 1. Except for certain emergencies, HMO will not pay for non-HMO services 2. Cost advantage of HMO may be result of attracting younger, healthier participants; if so, cost advantage diminishes with aging population Copyright 2009, The National Underwriter Company 4

Health Maintenance Organization (HMO) Chapter 46 Employee Benefit & Retirement Planning HMO Benefit Structure HMO employs or contracts directly with providers funding designed to reduce costs – medical service provided to subscribers for annual advance payment – payment based on HMO’s projected cost – HMO assumes risk of cost overage; creates incentive to reduce cost Copyright 2009, The National Underwriter Company 5

Health Maintenance Organization (HMO) Chapter 46 Employee Benefit & Retirement Planning HMO Benefit Structure HMO limits physician choice except – emergencies outside HMO’s geographic area – referral by primary care physicians to specialists Copyright 2009, The National Underwriter Company 6

Health Maintenance Organization (HMO) Chapter 46 Employee Benefit & Retirement Planning Types of HMOs Staff model HMO directly employs care providers who provide health care services Copyright 2009, The National Underwriter Company 7

Health Maintenance Organization (HMO) Chapter 46 Employee Benefit & Retirement Planning Types of HMOs Group practice model HMO contracts with medical group or groups that provide services to subscribers Doctors and other providers are not employed directly by HMO Copyright 2009, The National Underwriter Company 8

Health Maintenance Organization (HMO) Chapter 46 Employee Benefit & Retirement Planning Types of HMOs Staff and group practice models are called closed panel plans because subscribers must use providers employed by or under contract to HMO Copyright 2009, The National Underwriter Company 9

Health Maintenance Organization (HMO) Chapter 46 Employee Benefit & Retirement Planning Types of HMOs Individual practice association (IPA) HMO is association of individual doctors or medical groups An IPA is an open panel plan – subscriber can choose any doctor who is part of the IPA Copyright 2009, The National Underwriter Company 10

Health Maintenance Organization (HMO) Chapter 46 Employee Benefit & Retirement Planning Types of HMOs Success of HMO can depend on – desire to retain physicians used before HMO implemented – support of HMO by local medical community—greater support creates potentially wider choice for employees Copyright 2009, The National Underwriter Company 11

Health Maintenance Organization (HMO) Chapter 46 Employee Benefit & Retirement Planning Tax Implications Tax implications are same as for other types of health insurance Eligibility and coverage requirements, including COBRA are the same as for health insurance Copyright 2009, The National Underwriter Company 12