from Georgia Insurance and Fire Commissioner John Oxendine

Question and answer column from Georgia Insurance and Fire Commissioner John Oxendine

Question: I'm covered by an HMO. What happens if I need medical care while I'm on vacation, or somewhere else where I am out of the HMO's service area?

Answer: Emergency claims are billed to the HMO regardless of where they occur, provided the situation is a true emergency. Non-emergency cases must have the prior approval of the HMO.

Question: Are HMO members responsible for bills sent to them by a doctor or hospital?

Answer: Generally, no. Providers are prohibited by law from billing members for covered services rendered. They may, however, bill members for uncovered services, which would be any treatment not listed in the HMO contract, or which was not otherwise authorized by the HMO.

Question: What are the advantages or disadvantages of getting health coverage through an HMO?

Answer: With an HMO there are no large deductibles, and only small copayments. Also, members are not required to fill out lengthy claims forms. Some of the disadvantages include being limited to the HMO's designated hospitals and doctors. Members generally cannot use specialists without a referral from their primary-care physician. Also, if you have children who are attending college outside the service area of your HMO, they may not be eligible for coverage.

Please send your insurance or fire safety questions to: Insurance and Fire Commissioner John Oxendine, 716 West Tower, 2 Martin Luther King Jr. Drive, Atlanta, GA 30334.

Or call 404-656-2070 (toll free at 1-800-656-2298) for assistance with an insurance question. TDD services available at 404-656-4031.

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