Selecting a health maintenance organization (HMO) or a health care provider could be a tricky decision for a family or an organization. The family or organization is often stuck to the HMO or care provider for at least 6-12months after the selection. Most people choose health plans through their employer, through corporate organizations or the national health insurance scheme (NHIS). However, if you buy private health insurance or enroll in a social health insurance program such as NHIS, you may have the opportunity to choose from several health plans marketed by the several health maintenance organizations.

 

The following advisory are helpful in systematically selecting your preferred HMO

 

Preparation: 

Start as soon as possible: Do not rush into the selection of a HMO. The more time you have to scrutinize each, the better your chances of finding the best.

Back ground check: Since health insurance is regulated by the NHIS, you will need to pick a plan from a NHIS sanctioned HMO. The current list of NHIS accredited HMOs can be found HERE

You may also want to engage the advisory of an expert in the industry to assist you in the selection 

 

Need Assessment:

Make an aggregate list of all the health needs for your family and/or staff members. These may include specialist care, prescription drugs, maternity care, child welfare services, ongoing treatment for chronic illnesses etc. 

Determine your preferred healthcare providers or healthcare facilities and ensure they are on the HMO network. Find out if your preferred doctors/hospitals are on the HMO network. If not, will you be willing to change provider at the instance? If you’re not willing to change, is the HMO able to bring on your preference into its network?

You may also want to obtain references from other clients and your hospital/doctors. 

 

Cost analysis:

Determine the monthly or annual premium you can afford. Bear in mind all possible out of pocket payment as extra cost including co-payment, co-insurance and deductibles.*

Find out if your preferred plan covers pre-existing conditions and to what extent.

Familiarize yourself with the exclusions and ensure your most important needs are not excluded.

Find out how the HMO handles out of station care, out of network care and possible refund from emergency expenses.

 

Quality Assurance: 

You can properly assess the quality of services when you start utilizing it. Some pointers to good quality services by HMO includes; NHIS accreditation, HMO rankings and references from other clients of the HMO, especially pertaining to reliability and responsiveness.

It is important to have an incline into the HMO quality assurance processes. You might be interested in knowing how healthcare providers are enrolled, how seamless pre-authorization can be obtained, how healthcare provider reimbursement is carried out, and case & disease management. 

 

Practical Steps:

Practical Steps towards selection a HMO or a Health Plan:

Analysis of your health care needs and benefits required from health insurance plan

Analysis of previous cost and budgets for healthcare services.

Select a range of HMOs from which to choose from.

Call for proposals from HMOs; study and not just read the proposals.

Use a health insurance advisor if available.

Do background check on the HMOs.

Call for presentation and interaction with the HMOs

Negotiate cost and select the best

 

The best HMO should offer you high quality and cost effect services in a stable, reliable and responsive manner.

 

Dr Olawumi ADEKOLA MBBS, MPH, Cert. Insur. (WAII). ([email protected])

*Technical Words: Premium, Co-payment, Co-insurance and Deductible-:

http://www.nursingworldnigeria.com/2015/01/health-insurance-the-theoretical-basis-by-dr-lawumi-adekola