Kids and Health Care: HMO Benefits
HMO benefits are not limited to treatment resulting from illness or injury, but include preventative measures like routine physical examinations and programs for quitting smoking, losing weight and managing blood pressure. HMO members pay a set fee, usually on a monthly basis, which entitles them to a broad definition of "necessary health care."
HMOs provide a wide range of health care services. These required services are referred to as basic health care services. And any services or benefits provided by your HMO in excess of the basic services are referred to as supplemental health care services. Your HMO must provide you with a list of the basic services that are covered under the plan. For example:
- inpatient hospital and physician services for at least 90 days per calendar year for treatment of injury and illness;
- if inpatient treatment is for mental, emotional or nervous disorders -- including alcohol and drug rehabilitation treatment -- services may be limited to 30 days per calendar year. Treatment for alcohol and drug rehabilitation may be restricted to a 90-day lifetime limit;
- outpatient medical services when prescribed by a physician and rendered in a non-hospital health care facility (i.e. physician's office, member's home, etc.) including diagnostic services, treatment services, short-term physical therapy and rehabilitation services, lab and x-ray services and outpatient surgery;
- preventative health services, including well child care from birth, eye and ear examinations for children under age 18 and periodic health evaluations and immunizations; and
- in- and out-of-area emergency services, including medically necessary ambulance services, available on an inpatient or an outpatient basis 24/7.
Supplemental health care services may take the form of additional coverages over and above those provided as basic, or additional amounts of the basic benefits already provided.
Because an HMO provides service benefits rather than reimbursement benefits, they are required to follow guidelinesprescribed by the Insurance Department to assure quality service to members.
These guidelines specify the requirements for reasonable hours of operation and after-hours emergency care and standards to insure that sufficient personnel will be available to attend to your needs. The guidelines also require adequate arrangements to provide inpatient hospital services for basic health care and a requirement that the services of specialists be provided as a basic health care service.
