Question

If the HMO plan is considered primary, what will Sylvia’s portion of the charges consist of?

Answer 1

Ans) All medical services are provided based on a predetermined (per capita) fee and not on a fee-for-service basis. If the actual cost of services exceeds the predetermined (or capitation) amount, then the provider must absorb the excess in costs. This provides the incentive for the provider to control costs.

- A member patient must use the providers and hospitals that are identified by the HMO. The HMO will pay for any covered services that are provided by designated providers, hospitals, durable medical equipment, and pharmacies. Therefore preapproval must be granted through the PCP when and if a patient has to seek consultation or medical services out of the network. The exception to this is in the case of recognized emergency services.

Answer 2

An HMO plan is a capitated plan which would leave only a specific copayment amount as Mrs. Gonzales’ responsibility—which the secondary
insurance plan may pick up as part of the coordination of benefits.