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Description

A health maintenance organisation (HMO) is a type of medical insurance that charges a set annual fee for health care. It is a company that offers or arranges managed coverage for health insurance, self-funded health care benefit programmes, companies, and other organisations on a prepaid basis, serving as a liaison with health care providers (hospitals, physicians, and so on). The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options if the employer offers traditional healthcare options. HMOs often require members to choose a primary care physician (PCP), a doctor who serves as a gatekeeper for directing access to medical services, although this is not always the case. Internists, paediatricians, family physicians, geriatricians, and general practitioners are the most common PCPs (GPs). Patients need a referral from their PCP to see a specialist or other doctor, except in medical emergencies, and the gatekeeper will only allow the referral if the HMO guidelines make it essential. Some HMOs pay gatekeeper PCPs set fees for each given medical procedure they offer to insured patients before capitating specialists, while others do the opposite. A combination of an HMO and a conventional indemnity plan, open-access and point-of-service (POS) products are available. Until seeing a professional, members are not expected to use a gatekeeper or receive a referral. The typical advantages are applicable in this situation. The HMO advantages are applied if the member uses a gatekeeper. Beneficiary risk share for specialist treatment, on the other hand, could be higher. Utilization analysis is another way HMOs handle treatment. That is, they keep track of physicians and see whether they are providing more or less treatments to their patients than other doctors. In order to discourage members from contracting a preventable illness that would necessitate a large number of medical services, HMOs often offer preventive treatment at a reduced copayment or for free. Indemnity plans did not always include preventive services like immunizations, well-baby checkups, ammograms, or physicals when HMOs were first introduced. The HMO got its name from the inclusion of programmes aimed at keeping a member's wellbeing in check. Outpatient mental health coverage, for example, is minimal, and more expensive types of care, diagnosis, or treatment may not be covered. Case management, in which patients with catastrophic cases are diagnosed, and disease management, in which patients with chronic illnesses such as diabetes, asthma, or some types of cancer are identified, are two other options for handling treatment. In either case, the HMO becomes more involved in the patient's care, assigning a case manager to the patient or a group of patients to ensure that no two providers are providing overlapping care and that the patient is receiving appropriate treatment, preventing the condition from worsening beyond what can be helped.