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Health & Welfare: Health Maintenance Organizations (HMOs) and Accountable Care Organizations (ACOs)

A Health Maintenance Organization (HMO) is a managed care approach to health care. HMOs have defined networks of medical providers and facilities that members must use when seeking health care services. This managed care approach is intended to help control costs by providing efficient and effective health care.

An Accountable Care Organization (ACO) is a group of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their patients. ACOs are similar HMOs but typically utilize a more restrictive provider network that is often tied to a specific local or regional health care system.

General Information

When selecting an HMO or ACO plan for the first time, you'll be asked to choose a Primary Care Physician for all covered members. In most instances, your Primary Care Physician will handle your day-to-day health care needs. If you seek treatment from a specialist, you will be required to obtain a referral from your Primary Care Physician.

HMOs and ACOs typically require specific copayments for doctor visits, hospital stays and prescription drugs. A basic example would be a charge of $30 each time you visit a primary doctor. Some benefit levels combine the copayment and specific coinsurance in determining amount owed. The Coinsurance amount, typically 20 percent, is only applied at certain benefit levels and up to the maximum out-of-pocket limits of the HMO or ACO plan.

Remember, HMOs and ACOs usually require the use of specific networks of doctors and hospitals.

Enrollment Details

State Farm offers HMOs/ACOs to employees in many locations. However, there are some locations where your only health care option may be the State Farm Group Medical PPO Plan. Eligibility for an HMO or ACO plan is based on your Work or Reside ZIP code. Teleworker assignments where work and residence addresses are the same should contact the State Farm Benefits Center for assistance in determining HMO or ACO eligibility.

While it's important for you to know that State Farm offers HMOs and ACOs to employees and ensures appropriate benefits are provided, the plans themselves determine treatment approvals, not State Farm. Therefore, you should review all HMO or ACO plan documents carefully in order to make an informed decision on your health care selection.

State Farm encourages you to review your benefit options carefully and make informed decisions.

Disclaimer

This brief overview of Health Maintenance Organizations is not intended to be a complete explanation of plan features. For more detailed information and state exceptions, please refer to the online Human Resources Policy Manual for U.S. employees.