Understanding what your HMO actually covers, and what it does not

Having an HMO card does not mean that every service at every hospital is automatically covered. Your actual access depends on the provider, the plan or tier your employer or family selected, the hospitals in its network, benefit limits, waiting periods and whether authorisation is required.

The safest time to understand your cover is before you are ill. This guide explains the questions to ask so that a declined request or unexpected bill does not become the first time you discover how your plan works.

Start with the exact plan, not only the HMO name

One HMO can operate several plans with different hospital networks and benefits. Two colleagues may carry cards from the same company and still have different cover because of their employer's chosen package, grade level, dependant status or benefit limit.

When checking cover, have the member's full name, enrollee number, employer or sponsor, plan name and chosen primary provider available. Confirm that the membership is active and that the hospital is listed for that specific plan.

How payment arrangements affect the patient

Some primary care services are paid through an arrangement in which the provider receives a set amount for enrolled members. Other services are billed individually after they are provided. Patients do not need to master the payment terminology, but the arrangement can affect which facility starts the request and when a referral or approval is needed.

Ask a simple question: can this service be provided here under my plan today, or must my primary provider or HMO approve it first?

Pre-authorisation is not the same as a referral

A referral directs you from one clinician or facility to another. Pre-authorisation is approval from the HMO before a planned service is covered. Some treatments require both.

Common examples can include admission, surgery, advanced imaging, specialist review, physiotherapy sessions, maternity care and selected laboratory tests. Requirements vary by plan, so a service that was approved for someone else may not be approved in the same way for you.

Find out who submits the request, which documents are required, how you will know it has been approved and whether the approval has an expiry date. For a planned procedure, do not assume that a consultation approval also covers the operation, anaesthesia, admission, medicines, blood products or implants.

Waiting periods and maternity cover

A waiting period is the time between joining a plan and becoming eligible for a particular benefit. It is especially important for maternity, fertility treatment, elective surgery and some long-term conditions.

For maternity care, confirm the waiting period, antenatal visits, routine tests, scans, normal delivery, caesarean section, complications, newborn care and any financial limit. Also ask whether the baby is covered immediately after birth or must first be enrolled as a dependant.

Do not rely only on a general statement that maternity is included. Ask for the benefit details that apply to your exact plan.

Common limits and exclusions to check

• Medicines that are outside the plan's approved list or price limit
• Laboratory tests, scans or procedures above a stated frequency or value
• Dental, optical, fertility, mental health or physiotherapy benefits
• Pre-existing or long-term conditions with special rules or annual limits
• Medical devices, implants, consumables, blood and blood products
• Private rooms, meals for relatives and other non-clinical charges
• Treatment outside the approved network without prior permission

An exclusion means the plan does not cover the service. A limit means it may cover the service only up to a stated amount, number of visits or period. Ask which one applies.

What happens in an emergency

Urgent care should not be delayed while you search for a card or approval code. Go to an appropriate emergency facility or call for help. As soon as it is practical, provide the membership details and contact the HMO.

Plans may have rules about notification, network facilities and what happens after the patient is stabilised. Save the HMO's emergency contact number and understand those rules before you need them.

If a request is declined

Ask for the specific reason. A request may be declined because the membership is inactive, the hospital is outside the plan network, the benefit is excluded, a limit has been reached, required documents are missing, or a different provider must submit the request.

Then ask:

• Can the request be corrected or resubmitted?
• Is a referral, clinical report or test result missing?
• Is there an alternative covered service or facility?
• Can the decision be reviewed or appealed?
• If I self-pay, what exactly will I be charged for?

Keep the date, approval or reference number, name of the person you spoke with and any written response.

Your cover checklist

• Is my membership active?
• What is the exact name or tier of my plan?
• Is SkyHigh Medical Centre in my approved network?
• Does this service need a referral or pre-authorisation?
• What is included, limited or excluded?
• Are medicines, tests, admission and professional fees covered separately?
• What will I need to pay myself?

SkyHigh Medical Centre works with multiple HMOs, but benefits differ by plan. Contact the HMO desk with your provider name and enrollee number so the team can check the service you need before you commit.