SC Department of Insurance Health Maintenance Organizations

WHAT IS A HEALTH MAINTENANCE ORGANIZATION (HMO)?

A health maintenance organization, or HMO as it is commonly known, is an alternative to health insurance. It provides actual services, rather than just reimbursement, for health care expenses to members for a fixed monthly premium.

WHAT ARE SOME OF THE BENEFITS OF HMO COVERAGE?

HMO co-payments are usually less than traditional health insurance deductibles.

HMOs typically provide preventative services.

HMOs cover routine medical visits.

HMOs generally do not require members to complete claim forms.

DO I HAVE TO USE ONLY HMO PHYSICIANS AND FACILITIES?

An HMO keeps costs down by requiring that members use the "Network" of physicians and facilities. Only the HMO itself can authorize the use of an out-of-network specialist or non-contracted provider. Failure to obtain this authorization will result in the member having to pay for the non-authorized services.

WHAT IS A PRIMARY CARE PHYSICIAN?

As a member of certain HMOs, the member will have to designate a physician who will become the member's primary care physician or "gatekeeper". The primary care physician basically becomes your regular doctor. This physician will oversee all of your medical treatments and will arrange for referrals to other providers in the network. If necessary, the primary care physician will work with the HMO to arrange for a referral of medical treatment outside the network, if such services are not provided by the network.

WHAT IS AN "OPEN ACCESS" HMO?

If you are a member of an "open access" HMO, you may use any of the providers in the network, without having to receive a referral from a primary care physician. You should ask this question before purchasing an HMO policy.

WHAT HAPPENS IF I HAVE AN EMERGENCY SITUATION, OR I AM OUTSIDE THE AREA THE HMO SERVES?

HMOs have provisions, in their contracts, concerning emergency services, especially when you are outside their service area. It is important to read this provision of your policy before the need arises. It is also important to remember that the HMO, not the member, determines what qualifies as an emergency.

I HAVE A CHILD WHO IS GOING TO BE ATTENDING COLLEGE OUTSIDE MY HMO'S SERVICE AREA. WILL THE HMO COVER MY CHILD?

If your child will be attending college outside the service area that child is still subject to the same requirements as all other persons covered by the HMO. The HMO will only provide coverage to the child in an emergency situation, unless the child returns to the service area for medical services.

I AM WITH A GROUP THAT QUALIFIES FOR COBRA, BUT I AM LEAVING MY JOB AND MOVING TO ANOTHER STATE. WILL MY HMO COVER ME AND MY FAMILY UNDER COBRA?

As a COBRA recipient, you are considered part of the group, and are provided with the same coverage, and subject to the same limitations, as the other members of your employer's HMO group contract. You still must continue to use participating providers. If you move to a state that does not have physicians and hospitals that are participating providers in your HMO, the HMO will only cover you in a true emergency situation.

I AM NOT PART OF AN EMPLOYER GROUP. I AM AN INDIVIDUAL WHO WOULD LIKE TO JOIN AN HMO. IS THIS POSSIBLE?

Only two HMO products are currently marketed on an individual basis in South Carolina. They are: BlueChoic for Kids (available only to children under age 23) and may be contacted at 1-800-451-4275 or BlueChoic for Kids. Carolina Care Plan markets an individual HMO plan and may be contacted at 1-(800) 680-4637 or Carolina Care Plan

I AM ON MEDICARE AND WOULD LIKE AN HMO AS MY MEDICARE SUPPLEMENT (MEDIGAP) COVERAGE.

At the present time there are no HMOs in South Carolina selling Medigap coverage to individuals.  There are, however, several Medicare Advantage plans available in South Carolina.  To determine which Medicare Advantage plans are available in your area, please go to www.medicare.gov  Scroll down to the Search Tools and select Compare Health Plan Options in Your Area  Fill in the appropriate information, and you will be told all of the options that are available in your area.