Is there an HMO in your future?

Question: What do health maintenance organizations (HMOs) have in common with beets, cilantro or candy corn? Short answer, some people love them, some don’t. As in really, really don’t.

And the anti-HMO feeling many federal workers have could be costing them money in premiums and good service.

There are a wide array of HMOs available to federal workers/retirees during the current open enrollment period. It ends Dec. 13. Active and retired feds have plenty of plans and options to choose from. That includes traditional fee-for-service plans, like Blue Cross, GEHA and Aetna.

Despite the importance of actually shopping for the best deal during open season, experience shows that most people do nothing during the open season. They stay in the same plan they’ve been in for years. Even though that plan — excellent though it may be — has accumulated too many “heavy users” (older, more expensive) members, while younger, healthier people moved to other plans, or to the lower-premium standard or basic options of their favorite plan. Staying put for a long time — without shopping — means that many active and retired feds are now paying up to $2,000 more for the same coverage they could get with another option or plan. That’s the word according to Walton Francis, editor of Checkbook’s Consumer Guide To Health Plans for Federal Employees.

Francis says all of the plans in the Federal Employees Health Benefits (FEHB) Program are good. That includes fee-for-service plans as well as HMOs. But some, based on what you pay, are a better fit for you, your family and your lifestyle. And those things change over time.

So is an HMO for you? Francis cites these pros and cons you should consider when thinking about enrolling in an HMO:

Upside: HMOs come in two varieties. One, if a facility-based operation where most or all of the medical personnel and services are in one location. The other, called individual practice associations (IPAs), consist of different doctors in different locations. Both types usually offer good group consultation and coordination.

• Premiums and co-payments in many HMOs are lower than comparable fee-for-service plans.
• HMOs generally have systems for doctors to review each other’s practices.
• HMOs eliminate the inconvience  of submitting claims for costs and services. A major plus for many policy-holders.
• HMOs assure you access to a group of doctors,.
• They prevent a doctor from charging more than the plan will reimburse.

Downside: Many IPA plans often have participating physicians and hospitals but rarely a majority of those in the community, and rarely prestigious facilities — like the Mayo Clinic — in other states.

• Most group plans require you to go to one of their office locations except in emergencies.
• They limit your choice of phyisicians.
• Both types of HMO impose barriers to obtaining care as rapidly as you might like, such as wiats for the net avcailable appointment for non-urgent visits.
• Some HMOs, Francis writes, “rely very heavility on mid-level professionals such as nurse practitioners and physicians assistants.”

In many cases HMOs charge much lower premiums (in some instances half the premium of a non-HMO), and offer better catastrophic coverage (the limit to your amount) than many of the fee-for-service plans.

Things to consider is if your primary physician is in the network, do you like the idea of one-stop medical services and how important premiums, copays and paperwork to you.

Nearly Useless Factoid

By Alazar Moges

Source: White House

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