HMO Health Insurance: Eligibility & How It Works

Any individual seeking health care insurance coverage may qualify for an HMO, which is the acronym for Health Maintenance Organization, as long as that individual chooses a primary care provider within a specific HMO network.

Function

• An HMO functions as a prepaid health care plan and the network operates through a regulated group of health care physicians and organizations. The purpose of an HMO network is to provide health care to a designated group of individuals who must voluntarily designate their HMO provider.

Requirements and Qualifications

• Persons with an HMO qualify for in-network services only. Insured individuals must select a primary care physician from an approved list of providers, if insured through an HMO network. Pre-approval is required if an individual wishes to use an out-of-network provider. Anyone may enroll with an HMO and receive coverage, whether employed or unemployed.

Considerations

• The Health Maintenance Organization Act of 1973 allowed for the allocation of grant and loan funds to expanded health services and treatments provided by a predetermined physician. Today, HMOs are federally certified and regulated to ensure that the proper treatment and services are available to individuals within the network.