Global HealthcarePolicy & Law

Do HMOs Deserve A Bad Reputation? The Truth Of Managed Healthcare

3 Mins read
  • Should people REALLY be avoiding HMOs the way most of us try to? The truth about managed healthcare plans is that they're not all that we thought they were - and they might not be as bad as people think.

Have you ever heard people say that HMO health insurance is no good? It’s no secret that HMOs have a bad reputation, but it turns out this notion may not be entirely accurate.

According to insurance experts, more often than not, HMO members who run into issues with their plan, fail to do their research or ask the right questions to begin with. HMO myths are prevalent, but with a bit of expert advice, you can determine the coverage that best suits you.

So, What Is an HMO Plan?

Health Maintenance Organization plans represent a range of healthcare services accessible through a network of healthcare providers who are in agreement to supply health services to members. As an HMO plan member, you incur lower out-of-pocket healthcare expenses and get comprehensive coverage for your healthcare needs.

Separating Fact from Fiction: HMOs Don’t Live Up to Their Bad Reputation. 

Here are the most common HMO myths demystified:

This is at least partially false. The reality is that most healthcare providers have considerable networks of HMO doctors and additional contracted doctors at hand to serve you, so you have a wide array of options. Nonetheless, you do have to choose a primary care physician (PCP) as a standard procedure.

“Even the most restrictive of Medicare setups will give you a pretty robust selection of medical providers and facilities to choose from to receive your care, and Medicare in its original form lets you receive care from any physician who is willing to bill Medicare and Accept its payment,” explains Brent Crawley of The Premier Agency, a Medicare Insurance Agency in Peoria, AZ.

  • When one’s PCP is booked up while they’re sick, members cannot see a doctor.

On the contrary, in case of an emergency, members get the much-needed care where they need it, so long as it is within their network.  The primary care physician (PCP) only serves as the member’s healthcare provider of first resort and is not the beginning and end of their access to services. The PCP may also refer members to any specialist within their network provider.

  • Without paying a visit to their PCP every time, members cannot see a specialist.

This myth is far from true. Many healthcare provider networks will not deny members the go-ahead to visit specialists. However, discussing this with your HMO doctor could inform where you seek out specialized care.

  • The referral process for HMOs is quite the hassle.

As you seek out the specific services where referrals are needed, the bulk of HMO plan providers strive to service such requests seamlessly. Nowadays, you can get your paperless pre-authorization done online for an added layer of convenience.

  • When HMO members travel, they are not covered.

HMO providers will cater to most emergency or urgent care coverage during your travel. Your service provider will liaise with a healthcare provider where you are traveling, thus allowing you to maximize your insurance benefits.

The Truth About HMOs and Preventive Medicine.

In addition to the fact that your Health Maintenance Organization typically costs less than traditional health insurance plans, HMOs often arrange for integrated healthcare to stem future health expenses.

HMOs, to no small extent, focus on preventive medicine and preventive maintenance procedures. The physicals, rehabilitation programs and checkups offered to members, coupled with the perks presented to members who achieve set out fitness goals are measures geared towards promoting preventive medicine.

How Do I Keep My Doctor While Ensuring Continued Coverage?

Since your HMO won’t cover doctors outside its network, you need to be diligent when seeking healthcare services and comply with the rules laid out by your HMO provider.

If your doctor opts out of your HMO plan, you get notified of the developments; thus, you get to choose another doctor within your plan to ensure continued coverage.  On the plus side, you may also keep contact with the out-of-network doctor as your independent physician.


When choosing your HMO plan, do not make any assumptions, and go the extra mile to consult with an insurance expert.  Ask all the hard questions and be diligent in looking into the services offered by various networks and the doctors available within each plan before making your decision.

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