Changes in HMO plans between 2010 and 2021+

In the individual health insurance market in Georgia, Health Maintenance Organizations (HMO) are widespread. In fact there are no insurance companies in Georgia (outside of one in far North Georgia) that offer anything but HMOs on the individual market! These networks have somewhat of a bad reputation for being restrictive, small and not providing the best medical care. But HMO networks have come a long way in the past 10 years, we are going to go over some of the changes below!

HMO Plans and the Need for Referrals

It used to be that almost all HMO plans required referrals. Members would have a primary care doctor that was essentially a gatekeeper for the plan. Medical issues would be funneled through your primary care doctor, who would then give referrals for you to see various specialist. Most people did not like this system because it took more time and limited your choices. Instead of just picking an in-network specialist from a list and going to see them for an issue, the additional step of going through your primary care was necessary. And then you would go see the specialist your primary care referred you to.

But that has changed on most HMO plans available in 2021. Most plans no longer require a “gatekeeping” primary care doctor in order to see various specialist. This is because most of the HMO plans are a part of the big hospital networks of doctors that have every specialist under the sun available. So as long as your specialist is in network, you can see then whenever you would like.

Note there are still some plans that require a referral, especially in the metro Atlanta area. That is why it is important to talk to an agency like ours before you buy! We will make sure you know exactly what insurance you are getting and how it works!

HMO Plans with Extremely Limited Networks

If you are familiar with health insurance plans from 2010 and before, then your perception of HMO networks might be that they are very limited. This used to be the case, especially when compared to PPO networks. And while it is true the HMO networks are more limited in scope, many of the HMO providers in Georgia have quite large networks. Certainly large enough for members to have a wide array of hospitals and doctors to choose from.

Many 2021 HMO networks are continuing to grow each year. This is because on the individual market, HMO’s are the only option available for the vast majority of Georgia residents. Due to this many providers need clients and are finally getting in network with the various HMO offerings in Georgia. We anticipate that this trend will continue while HMO plans dominate the marketplace in Georgia.

A Standout HMO: Kaiser’s Integrated Care Model

Most HMO plans operate on a similar basis, only one stands out as different from the rest. Kaiser is so different because they are doing much more than providing members with a network and insurance. They own their own doctors, facilities and the hospitals they contract with take on the Kaiser model. This means that Kaiser is invested in the health of its members like no other insurance company. This also means that they have distinct advantages when it comes to providing healthcare for their members. Their systems are interconnected and allow for great coordination of care between different providers. They also have great systems in place such as only giving their doctors bonuses based on health patient outcomes. Their whole system is focused on providing their members with excellent healthcare at an affordable price.

How Can I Check if my Doctors are in Network with a Particular HMO?

Before you purchase an HMO plan.  If you have doctors that you want to be able to go to and have your new plan pay for their services, it is extremely important to do your research BFORE you sign up for a new plan. This needs to be done by searching at the providers website but then confirming with the doctor or providers billing office that they are indeed in network with that carriers very specific Individual HMO network. Do not trust a simple website search that says your doctor is in network, these are often outdated and wrong.

Before you seek a new service using your HMO plan. You need to double check that a provider is in network, before you show up for your appointment. This will help you avoid wasting time or money by going to a provider not in network.

Does all this seem overwhelming? Don’t worry, we can help you make sure your doctors are in network and that you understand how your HMO plans works! Give us a call or book an appointment with us to get started! 


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