A health maintenance organisation (HMO) is a type of health insurance plan managed by a private organisation. The organisation collaborates with a specific network of doctors, specialists, and hospitals to provide basic and preventive medical care services such as routine check-ups, vaccinations, and immediate medical care to their subscribers at an agreed fee.
It is one of the most commonly used health insurance plans in Nigeria. They are registered and regulated by the National Health Insurance Authority (NHIA) to help provide quality healthcare services at an affordable price.
HMOs provide health insurance coverage to their subscribers (also called enrollees or members) for a monthly or yearly prepaid fee (premium). Compared to other health insurance plans, these premiums are more affordable, thanks to their network approach.
The following are the ways HMOs work:
- Each HMO has a list of hospitals and clinics they have entered into contracts with to be part of their in-network providers to provide healthcare services to their subscribers. They also offer different healthcare plans with different premiums (costs) and different coverage levels.
- These healthcare providers that enter into contracts with the HMO negotiate the cost of offering their services to their subscribers, which is usually at a discounted rate. This enables HMOs to offer their members lower premiums.
- The HMO markets its services to individuals and companies looking to provide healthcare insurance for themselves, their family members, or employees. After making a decision on the plan and the desired coverage levels, the individual or company pays the HMO premium to enrol in their insurance coverage for a set period.
- When it is time to get treatment, the subscribers choose healthcare providers from the HMO list or service providers while the HMO pays the providers directly for their services.
HMOs in Nigeria offer a lot of benefits to their members. As someone registered with an HMO:
- You will have the opportunity to select a primary care doctor and healthcare facility of your choice from the list of medical experts and facilities collaborating with the HMO.
- You will have a network of providers available to you, to coordinate your care.
- There is usually no limit to the number of primary care visits.
- The monthly or annual premiums are fixed and lower than other types of health insurance plans.
- Out-of-pocket expenses are usually lower when you have a HMO plan. The co-pay and cost of prescriptions for HMO plans are usually cheaper with little or no deductibles.
- Generally, HMOs provide a higher quality of medical care. This encourages patients to seek early treatment and go for routine check-ups.
Accessing proper medical care can be expensive, but with HMOs, getting good healthcare services is more affordable. There are different HMOs, and each has its care plans and list of coverage. It is important to choose a HMO that meets your medical care needs. You need to consider the following before signing up with any HMO:
- Cost and coverage benefits: to find the best deal, compare the cost of premiums for different HMO plans and the coverage benefits.
- Out-of-pocket expenses: factor in any costs not covered by the plan, such as co-pays or deductibles (out-of-pocket expenses).
- Provider network: go through the HMO’s network of doctors and hospitals. Verify if those providers have a good reputation.
- Consider your healthcare needs: based on your current health condition, you need to determine if you need regular check-ups or frequent specialist care. Find out if the HMO network you want to sign up with covers all the services you need and what the associated costs might be. You also need to determine if you will sign up for the HMO plan as an individual or for your entire family. If you will sign up for your entire family, you need to think carefully about the health condition and needs of the individuals in your family.
- Accessibility: Check if the HMO has convenient appointment hours and if the locations of the providers and care facilities on their network are easy to access.
- Customer service: Check online reviews, testimonials, and ratings to find out if the HMO is reliable and how well they serve their customers.
You also need to find out if the HMO has 24/7 customer support available in case of an emergency. After all, the last thing you want when you are ill is a HMO that will stress you out or give you more headaches.