Health Maintenance Organization (HMO) Plans HMO health plans deliver great value for your health care dollar. You and your employees get full access to in-network providers while effectively managing health care costs.
HMO PLANS OFFER:
FREE PREVENTATIVE CARE. 100% coverage for preventive services, such as annual exams, screenings, and more, when performed in-network. $0 COPAY PREVENTIVE DRUGS. There is no cost associated with select preventive drugs that target common medical conditions, such as high blood pressure and diabetes. AFFORDABLE ACCESS TO ASPIRUS NETWORK PROVIDERS. Aspirus offers five regional hospitals in Wisconsin, four more in Michigan, 50 clinics, and more than 400 physicians.
With an HMO plan, it is recommended that each member choose a primary care practitioner (PCP) who will help coordinate overall medical care. There is no referral necessary to see an in-network specialist, but some services will require review and prior authorization. If you receive care from an out-of-network provider, the HMO will not pay for that care unless prior authorization was approved or the condition was deemed an emergency.
If the prior authorization is approved or you seek care from an out-of-network emergency room, the non-participating reimbursement value will apply to out-of-network providers and services. The amount the plan pays is the allowed amount for any covered service. But if an out-of-network provider charges more than the allowed amount, you may have to pay the difference.
Here's an example: You go to an out-of-network hospital, which charges $1,500 for an overnight stay. If the allowed amount is $1,000, you may have to pay the $500 difference.