We’re considering enrolling in an Aetna HMO plan for next year. Does anyone have experience, good or bad, with this plan? Or, does anyone know of any concerns we should be aware of before enrolling?

Full Disclosure: I am employed by an HMO that does business in the Atlanta Metro market.

I believe that an HMO can provide its contract holders access to excellent, quality healthcare. With that said, you must also understand that HMOs direct your choice of who you can see and the types of therapeutics to which you have access. In the case of diabetes, this means that the brand of blood glucose monitor, injectable or oral medication may be different than the one that you currently use or prefer, or will be available only with a high co-payment. Also, you may have to change from your present primary care and specialty care providers. I also believe that the preventative care philosophy is a very important part of treatment. Does an HMO provide access to statins or foot and eye examinations?

The issues that I would consider are:

Are my current providers participating providers in the HMO?
If not, will I be satisfied with the providers that are in the plan?
Are my preferred providers authorized to provide service at the hospitals that are contracted to the plan?
What are the preferred DME and pharmacy formulary brands?
Will I pay extra to have brand name DME and pharmacy items for my care?
What types of preventative care programs are available?
What is the NCQA rating for the plan? (Excellent is best)
What is the relative percentage of complaints sent to state regulators compared to other plans?

These are the questions that I would ask when considering joining an HMO. For further information on the types and availability of health coverage in Georgia, I recommend that you take a look at the web site compiled by the Georgetown University School of Health Policy at healthinsuranceinfo.net.

DSH