Who Qualifies for an HMO?

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.