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Health Maintenance Organization

Definition

Health Maintenance Organization (HMO): In the Canadian insurance context, an HMO is a private or non-profit benefit plan that contracts with a network of doctors, clinics, hospitals, and other providers to give enrollees a fixed set of medically required services for a set monthly fee. Services are delivered or coordinated by a primary-care physician (family doctor or nurse practitioner) who acts as the enrollee’s first point of contact; referral from this provider is generally required before seeing a specialist or obtaining most diagnostic tests. Unlike provincial public coverage—which pays for “medically necessary” physician and hospital services under the Canada Health Act—an HMO plan typically bundles preventive and routine services (eye exams, dental check-ups, prescription drugs, paramedical treatments, etc.) that may not be fully publicly funded. The plan covers these services only when obtained within its designated network; seeking care outside the network usually results in reduced reimbursement or none at all. Enrollees pay fixed monthly plan premiums (often subsidized by an employer) and minimal copayments or deductibles at the point of service, with the HMO assuming financial risk for the agreed-upon basket of care.

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