Definition Of Health Maintenance Organization (hmo) In Insurance

Definition of "Health maintenance organization (hmo)"

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Prepaid group health insurance plan that entitles members to services of participating physicians, hospitals, and clinics. Emphasis is on preventive medicine. Members of the HMO pay a flat periodic fee (usually deducted from each paycheck) for these medical services:

HMO Managing Physician & new member can select an HMO physician, who is then responsible for providing all of his or her health care needs. If necessary, the managing physician makes arrangements for the member to see a specialist.
HMO Copayment a. member may be required to pay an amount in addition to required periodic payments, for example, a $5 flat fee for each visit regardless of how expensive the services may be. Or, for each prescription, to pay a flat amount of $2 regardless of the actual cost.
HMO Hospital Services include, among others, room and board, operating room, laboratory tests, radiation, medications, and physical therapy.
HMO Physicians and Surgeons Services in Hospital include surgeons and related medical specialists, with no co-payment.
HMO Outpatient Hospital Care members receive the same services that are provided under Inpatient Hospital Services, as authorized by the managing physician; there is no co-payment.
HMO Outpatient Health Services Provided at HMO Facility-include physician services, preventive health services, diagnosis and treatment services, skilled nursing facility services, mental health and/or alcohol and drug abuse services, dental care under specific circumstances, and emergency services in and out of the HMO area. A co-payment may be required. HMO exclusions include custodial care, experimental procedures, conveniences not medically related such as television, radio, and telephones, and cosmetic care except for medically necessary reconstruction.