But what about HMO’s? Most employees and employers are familiar with their basic functioning, but much of what is reported spins them in a poor light.
How might HMO’s prove beneficial for small and large companies? How might employees benefit from having them? What are the downsides of offering an HMO?
HMO: ¿Qué son y cómo funcionan?
HMO significa Organización para el Mantenimiento de la Salud. Requieren que usted seleccione un Médico de Atención Primaria (PCP) en la red. Ese médico es responsable de derivarlo a especialistas y hospitales dentro de la red según sea necesario. Cada vez que necesite asistencia médica, debe consultar primero a su PCP.
After that initial visit, they determine where to send you next if your medical issue requires further treatment. HMO’s also do not cover out-of-network medical care except for extreme emergencies. You are also required to contact your PCP as soon as possible to inform them of your emergency.
Es posible que a los pacientes que ya cuentan con un médico de cabecera en quien confían y al que prefieren no les gusten los planes HMO simplemente porque ya no se les permite utilizar a ese médico sin pagar de su bolsillo. Por lo general, tampoco hay un límite en cuanto a los costos de atención médica por año con el plan. Según el plan, es posible que se cubra o no el tratamiento especializado.
Additionally, instead of deductibles, HMO plans frequently charge a minimum amount or copayment for each doctor’s visit. That copayment may be as little as $5 or as much as $50 for visits. This amount is also applied to prescription medications, making more serious illnesses more expensive as the cost can be dictated by the percentage.
Now that you know the basics of what an HMO is, let’s talk about the benefits it offers to both employees and employers.
Beneficios para los empleados
The greatest benefits of an HMO is cost-savings. HMO’s dictate what providers can and cannot charge. This eliminates unnecessary spending and doctor’s visits along with outrageous costs for standard services. Employee’s benefit in the form of lowered copayments for the services they receive. Healthy families and single folks benefit most from HMO plans.
Preventive health care is another huge bonus for using HMO’s. HMO’s cover virtually all preventive health care services. The end goal is to keep patients happy and healthy so they avoid higher and unnecessary medical costs down the road. HMO’s also attempt to avoid high costs by rewarding doctors for providing only the necessary medical coverage required to keep patients healthy.
HMO’s, despite what some might say, have a healthy network that allows employees to select the best PCP for them and their families. Additionally, low prescription costs and all basic preventive care allow employees to take their health into their own hands.
Los beneficios dentales, de la vista y otros beneficios de bienestar se pueden ofrecer por separado, lo que reduce aún más los costos ya que la mayoría de los empleados optarán por mantener los costos bajos en lugar de agregar una cobertura innecesaria.
Costos de HMO para empleadores
HMO’s cut costs by as much as 20% of the final premium. Additionally, employers aren’t limiting their employees to certain doctors or providers, as there are usually thousands of capable and qualified physicians. Lower monthly premiums require lower employer contributions, which overall lowers the costs for employers.
Another factor many don’t consider is claims data. If employer groups are hoping to explore their options for level-funded or self-funded plans in the future they need solid claims data to get a better rate. HMOs provide some of the best claims data because they are cost-containment focused. Physicians focus on the quality of the treatment instead of offering unnecessary services thereby reducing claims.
PPO’s, on the other hand, often result in higher claims data simply because of the vetting process for each claim. HMO’s make it more difficult for employees to be subject to fraud in any way as well. Fewer claims also equal a better claims experience, which in turn leads to better rates for level funded or self-funded plans.
En términos de costos para los empleadores, si bien pueden tener que pagar más de 90% por los costos, las HMO son considerablemente más económicas en cuanto a primas. Además, si los empleados desean agregar atención fuera de la red y optan por no utilizar el PCP dentro de la red, aún pueden hacerlo, pero pagarán de su bolsillo. Los empleadores no son responsables de pagar la diferencia ni de pagar el servicio, ni tampoco lo es la HMO.
The downside to offering an HMO plan is that many employees are looking to work for companies that provide comprehensive insurance benefits. HMO’s don’t include vision and dental, and the copayments can increase for specialized services. Additionally, there are fewer drugs on their formulary and the process of seeing a specialist can be frustrating at times. In terms of keeping employees happy, an HMO doesn’t always do the best of jobs.
¿Debería su empresa ofrecer un HMO?
La respuesta a esa pregunta debe basarse en varios factores, entre ellos:
- Análisis de su grupo. ¿Tienen requisitos especiales que hacen que una HMO sea más frustrante de lo que vale?
- Datos de reclamaciones. ¿Tiene previsto ofrecer planes autofinanciados o con financiación a plazos en el futuro? Si es así, una HMO es una buena opción.
- ¿Qué importancia tienen los beneficios para su empresa y sus empleados?
- ¿Qué otras opciones de planes podría ofrecer a sus empleados?
While a PPO always seems like the best route to take, simply because employees have greater options, it can cost far more than it is worth. PPO’s can climb in expenses because there is no cost-containment. However, HMO’s via employer-sponsored plans can also leave employees dissatisfied with a lack of control over their own health. Premiums are more affordable, but they leave something to be desired in the realm of specialized services.
¿Todo esto ya te ha dejado perplejo? Si es así, queremos ayudarte.
At Primary Care Insurance Solutions, we strive to provide high-quality advice your company can count on. HMO’s and PPO’s are complicated. We’ll work with you to demystify the selection process and give you a greater overview of what you and your employees can expect from each plan.
Visit us in person or give us a phone call for a quick chat about your employer-sponsored plan in Houston, Texas and we’ll walk you through the process of selecting the right one for your team.
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