HMO Information

One of the best ways to judge a plan's quality is to talk to members and providers who have a history with the company.

Friends and family are an invaluable resource in telling you how a plan functions and whether their needs are served. Ask them how easy they find access to specialists, how quickly they can get appointments with their primary care provider, and whether they feel they always receive the health care that they need. Keep in mind that these are subjective answers, and make sure you find out what they mean by a "long wait", etc.

Ask a primary care provider the process for referring patients to specialists. Do they have to let authorization for each referral? Find out how complicated the process is and how much time it usually takes to make an appointment with a specialist.

One of the most important aspects of quality is the caliber of the providers. Having providers who are available, knowledgeable, and willing to take the time to go to bat for you with the administrators is priceless.

Emergency Care
Does the HMO allow you to get emergency care without first calling an HMO number? Does the HMO define an emergency as a problem that the average person would consider an emergency? (If not, you could wind up paying the entire emergency room bill if your problem turns out not to be a true emergency.)

Care From Specialists
Does the HMO allow women to have an ob-gyn doctor as their primary care provider and/or see an ob-gyn doctor for an annual check-up without first obtaining a referral? Does the HMO provide you with an adequate choice of specialists?

If you have an ongoing chronic disease, does the HMO allow you to see an appropriate specialist without making you first see your primary care provider each time you need care? (If it doesn't, you could waste a lot of time with doctor visits to your primary care provider when you really need to see a specialist).

Does the HMO have a clear arrangement for referring you to a specialist if you were to have life-threatening conditions, or other problem that requires specialty care over a long period of time?

If the HMO doesn't have a doctor available who can meet your needs, does it have a clear arrangement for referring you to specialists who are not part of the HMO plan?

Travel and Waiting Times
Does the HMO assure you that you can get an appointment in a reasonable length of time, especially if you have an urgent problem? (If you only need a checkup, you can expect to wait for several weeks to get an appointment.)

Can you get to the HMO doctor's location without traveling for more than 30 minutes?

Continuing Care
If you are pregnant or have a life-threatening or long-term condition, does the HMO allow you to keep seeing your former doctor for awhile before you have to switch to a doctor in the new HMO?

If the health care provider you are seeing for pregnancy or for a life-threatening condition no longer contracts with the HMO, will the HMO allow you to keep seeing your provider for a period of time?

Grievances and Appeal of HMO Decisions
Does the HMO provide you with a description of how it makes decisions of what is and is not appropriate care?

Does the HMO give you written notice that you can ask for an appeal if your HMO refuses to pay for a service, or refuses to allow you to see a specialist, or have a particular test or treatment?

Does the HMO provide you with a detailed description of how you ca appeal if you are denied care, or care is reduced or stopped?

Does the HMO allow you to make grievances and ask for appeals verbally, rather than only in writing? Does the HMO offer any assistance to patients who want to ask for an appeal?

Does the HMO guarantee that you will receive a decision on your appeal?

Does the HMO guarantee that you will receive a decision on your appeal within a reasonable time, say two weeks?

Does the HMO have a way for you to get an appeal decision more quickly, say in three days in the case of a life-threatening situation.

Confidentiality of Patient Records
Does the HMO promise in writing not to share information about you with anyone other than those providing your care, processing payments on your behalf, or anyone else you specifically say should get the information?

Does the HMO promise in writing not to release information from your medical record to your employer without your permission?

Communications
Does the HMO respond to your questions clearly and promptly?