Definitions for "Health Maintenance Organization"
Related Terms:
Hmo, Health maintenance organizations, Exclusive provider organization, Network, Managed care plans, Closed panel, In-network provider, Managed care organization, Out-of-network provider, Preferred provider organizations, Independent practice association, Epo, Nonparticipating provider, Preferred provider organization, Individual practice association, Provider network, Managed care plan, Staff-model hmo, Ppo, Managed care, Participating physician, Managed health care, Network provider, Covered entity, Point of service plan, Preferred provider network, Participating provider, Medicare hmo, Point-of-service plan, Alternative delivery systems, Pso, Closed access, Dhmo, Non-participating provider, Php , Carve-out, Part b, Medicare part b, Out-of-network care, Dental health maintenance organization, Out-of-network, Medicare managed care plan, Mco, Group model hmo, Prepaid health plan, Out-of-network services, Point-of-service, Pccm, Fee-for-service plan, Lock-in
HMO. A form of health insurance combining a range of coverages in a group basis....
A system of managed health care in which patients must see approved health care providers. HMOs typically offer coverage with no deductibles and low per-visit fees. [Go to source
Organization that provides a wide range of comprehensive health care services for a specified group for a fixed periodic prepayment
A type of health care plan that offers patients medical coverage with low or no copayments for visits to doctors and hospitals that belong to that HMO network.
Organization licensed by the state to provide comprehensive health services to enrolled subscribers and their dependents.
A type of managed health care system that contracts with medical facilities, physicians, employers, and sometimes individuals to provide medical care to a group of people known as "members." Generally, members of HMOs don't have any significant "out-of-pocket" expenses because the medical care is most often paid for by an employer at a fixed price per patient.
An organization to which Medicare pays a pre-determined annual fee for each Medicare eligible person who enrolls. The HMO then provides the older person with any necessary medically authorized health care during the year.
Refer to HMO for definition. See: Managed Care
A term applying to an organization or set of related entities organized for the purpose of providing service benefits to an enrolled population, for a predetermined fixed periodic amount to be paid by the purchaser (e.g., government, employer, individual).
also known as Health Care Plans or Managed Care Organizations HMO MCO An organized system that arranges or provides a set of health care services to members in return for a prepaid or periodic charge paid by or on the behalf of the enrollees. (There are varying federal and state definitions for these entities.)
a type of managed care plan in which the member is required to select a primary care physician to provide and coordinate all covered medical care, including referrals for specialist services.
A form of health care which provides services for a fixed period on a prepaid basis.
A medical or vision insurance plan that requires beneficiaries to use only the facilities and physicians who have contracted with the plan to provide services to beneficiaries. Care provided to a patient by a facility or physician that is not contracted by the Health Maintenance Organization is not normally a covered benefit of the plan, except in some emergency situations or with prior authorization from the plan.
A health plan that offers comprehensive health coverage to its members for both hospital and physician services for a fixed fee (an amount per member per month), with a small amount collected at the time of each visit. An HMO contracts with health care providers, e.g., physicians, hospitals and other health professionals, and members are required to select a primary care physician from among the network providers, and to use network providers for all health services. Model types include staff, group practice, network and IPA (see separate definitions).
also HMO. A pre-paid hospital and medical plan with a defined membership which provides comprehensive health services. The plan controls which providers are seen by the patient and uses specific, participating hospitals for advanced care. HMOs are usually paid a fixed amount per member per month, regardless of how many services a member uses. This form of payment is called "capitation."
a form of prepaid group practice. They provide a comprehensive range of services on a fixed contract basis, which is paid for in advance by people enrolling in the organization.
An insurance-like plan for providing health care, including preventive health care, on a prepaid basis to subscribing members of the plan.
A type of health benefits plan that provides care through a network of doctors and hospitals in particular geographic or service areas. HMOs coordinate the health care services you receive. Your eligibility to enroll in an HMO is determined by where you live or, for some plans, where you work. Some FEHB HMOs have agreements with providers in other service areas for non-emergency care if you travel or are away from home for extended periods.
Health care centers that stress preventive health care, early diagnosis, and treatment on an outpatient basis. An organized system of health care delivery and financing that provides a broad range of services to a voluntarily enrolled group for a fixed and periodic payment. The HMO participant pays a flat annual premium and is entitled to medical check-ups and routine health care, plus major medical coverage. (See: prepaid hospital service plan.)
Prepaid health plans in which you pay a monthly premium and the HMO covers your necessary medical treatment. You must choose a primary care physician from within the network to coordinate all of your care. All specialty referrals need to be authorized by your primary care physician.----------[ Back
An organization which provides comprehensive healthcare coverage to its members through a network of doctors, hospitals and other healthcare providers.
A type of managed care plan in which doctors, hospitals and other health care providers agree to provide a comprehensive range of medical services to participants at negotiated rates.
A health care plan that coordinates and offers medical services through a group of contracted individual doctors (or groups of doctors), area hospitals, and other medical service providers. Normally requires selection of a Primary Care Physician (PCP) or a Primary Medical Group (PMG).
Health insurance plan that entitles individual members to an array of medical services provided by participating physicians, hospitals, and clinics.
A type of medical insurance under which insurance companies must approve certain services (other than emergencies), hospitalization, or tests. Patients are limited by participating doctors and hospitals, and must be referred from their primary care physician (PCP) to specialists. HMO practitioners get paid both by capitation (a fee the company pays the practitioner with each patient who signs on) and by volume of patients, which is sometimes very large.
An HMO is a prepaid medical service plan which provides services to plan members. Medical providers contract with the HMO to provide medical services to plan members. Members must use contracted providers. The emphasis is on preventive medicine, and it is an alternative to employee benefit plans. Employers of more than 25 persons are required to offer the alternative of HMO to employees, but not if the cost exceeds that of present employee benefit plans.
An HMO is a prepaid health plan delivering comprehensive care to members through designated providers, having a fixed monthly payment for health care services, and requiring members to be in a plan for a specified period of time (usually 1 year).
A type of insurance plan.
An insurance plan that pays for preventive and other medical services provided by a specific group of participating providers.
A Health Maintenance Organization (HMO) is a health plan that consists of a network of contracted doctors and hospitals to provide treatment to members of the HMO's plans. An HMO may consist of dedicated facilities where all care is received at the HMO's facilities or selected individual physicians, hospitals and other service providers contracted on an individual basis. An HMO uses the Primary Care Physician (PCP) concept to coordinate all your health care.
This is a type of insurance which is inexpensive but which limits medical care choices.
A public or private organization providing, either directly or through arrangements with others, a comprehensive range of health services to enrolled members who live within a specified service area. Payment is based on a predetermined periodic rate, or periodic per capita rate, without regard to the frequency or extent of covered services furnished to any particular member. The HMO must also meet statutory requirements.
An insurance plan encompassing a network of health care providers including doctors, hospitals, pharmacies, and other medical facilities and professionals where an individual and his/her employer pay a fixed monthly fee for services, regardless of the level of care.
An organization that has made agreements with doctors and other health care professionals to provide preventive and sick care to members at a low preset fee.
HMO): A type of health care organization that manages and finances its members’ care. HMOs emphasize preventive care in order to keep their members healthy. HMOs have exclusive provider networks and often use primary care providers as "gatekeepers." Gatekeepers are responsible for arranging the patient’s referral to a specialist or admission to a hospital. While most HMOs use gatekeepers, some HMOs have "open access" plans. These plans allow the patient to choose any primary care provider or specialist in the network without a referral. HMOs also may use reimbursement systems such as fixed payments for each member (called " capitation") or performance incentives to encourage providers to be more cost conscious. HMOs may contract directly with physicians in the community, or may contract with networks of physicians. This arrangement is called a network or IPA model HMO. HMOs may have their own doctors on salary or in an exclusive contractual arrangement. This is called a (group- or staff-model HMO).
There are various types of HMOs. In staff-model HMOs, such as Kaiser Permanente, you typically choose from the care providers they have on staff. In other HMOs, you choose your care providers from listings of independent care providers with whom the health plan has negotiated rates.
An organized system for providing health care in a geographic area that assures delivery of basic and supplemental health maintenance and treatment services to a voluntarily enrolled group of people for a predetermined, fixed prepayment fee. As a member of a Health Maintenance Organization or HMO, you must receive all your care from a panel of participating physicians, consultants and facilities. This panel is sometimes referred to as participating providers or as a participating network. To receive your benefits, all services need to be provided within the participating panel and rendered by or referred by your primary physician ("PCP"). Except for emergencies, certain Ob/Gyn services and certain other services, when your PCP determines you require the services of a specialist, he or she will contact us to request approval.
Aetna offers various HMO plan designs with varying copayments. Except for direct access programs, emergency situations and for out-of-area urgent care, members may access health care services only through their chosen primary care physician (PCP). The PCP coordinates all aspects of a member's care covered under the plan. Specialty or facility services are not covered unless approved or directed in advance by the member's PCP. | | | | | | | | I-L | | | | P-Q | | | T-Z
An entity that offers prepaid, comprehensive health coverage for both hospital and physician services with specific health care providers using a fixed structure or capitated rates.
An organization that provides health care for a geographic area and accepts responsibility for delivering an agreed set of health maintenance and treatment services to a voluntarily enrolled group. An HMO collects a predetermined periodic payment paid in advance on behalf of each individual enrolled.
Organization that has management responsibility for providing comprehensive health care services on a prepayment basis to voluntarily enrolled persons within a designated population.
A managed care plan that combines the function of insurer and provider to give members comprehensive health care from a network of affiliated providers. Enrollees pay limited copayments and are usually required to select a primary care physician through which all care must be coordinated. HMOs generally will not pay for services obtained from a non-network provider or without a primary care physician's referral. HMOs often place an emphasis on prevention and careful assessment of medical necessity.
A legal corporation that offers health insurance and medical care. HMOs typically offer a range of health care services at a fixed price.
an organization that provides health care through a network of doctors, hospitals and other medical professionals. HMO members must use the network to be covered for that care. HMOs are a part of Managed Care (see definition below).
An entity with four essential attributes: an organized system for providing health care in a geographic area, which entity accepts the responsibility to provide or otherwise assure the delivery of an agreed upon set of basic and supplemental health maintenance and treatment services to a voluntary enrolled group of persons, and for which services the HMO is reimbursed through a predetermined, fixed, periodic prepayment made by or on behalf of the amounts of actual services provided (from the report of the Committee on Interstate and Foreign Commerce on the HMO Act of 1973, P.L. 93-222, in which the term is legally defined, section 1301 of the PHS Act).
Managed care health plan that uses an established network of health care providers - doctors, specialists, hospitals, laboratories and pharmacies in which provider network participants have agreed with the insurance carrier to provide health care services for a negotiated price. Generally, the only out-of-pocket expense for the patient is a small co-payment made at the time the service is received. In an HMO, the patient must choose a Primary Care Physician (known as a PCP) who provides most services and must authorize the use of other services, such as hospitalization, referrals to specialists and testing.
A medical plan that offers its members a wide range of medical services from a specific group of medical providers.
A managed care organization that combines the functions of a health insurance company and a health care provider.
an organization that provides comprehensive medical care to a voluntarily enrolled consumer population in return for a fixed, prepaid amount of money
A health plan, either for-profit or not-for-profit, that provides comprehensive medical services to its members for a fixed, prepaid premium. Members must use participating providers and are enrolled for a fixed period of time.
Organization that provides comprehensive health care services for subscribing members in a particular geographic area.
Prepaid health plans in which you pay a monthly premium and the HMO covers your doctors' visits, hospital stays, emergency care, surgery, preventive care, checkups, lab tests, X-rays, and therapy. You must choose a primary care physician who coordinates all of your care and makes referrals to any specialists you might need. In an HMO, you must use the doctors, hospitals and clinics that participate in your plan's network.
An HMO (Health Maintenance Organization) is a managed care program. Most HMO's require each family member to select a Primary Care Physician from an approved list provided by the HMO. This Primary Care Physician will then direct all of your medical treatment including referring you to a specialist. This specialist is usually a member of the HMO you are insured with. Failure to see your selected Primary Care Physician first (unless in an emergency situation) can result in sharply reduced benefits or no benefit at all. As a general rule, HMO's provide the most comprehensive medical care; such as routine office visits, physical exams, well-baby care and immunizations. HMO's also feature low office visit co-payments and usually do not require the filing of claim forms.
An organization consisting of hospitals, physicians, and other health care personnel who have joined together in an central facility to provide necessary health care services to its subscribers.
A health care financing and delivery system that provides comprehensive health care services for enrollees in a particular geographic area. HMOs require the use of specific plan providers.
an organization that provides a comprehensive range of health services including hospitalization, preventive care, and diagnosis. HMOs require members to use specific health care services (doctors, hospitals, etc.) in the HMO's "network." The HMO will pay less or nothing if members go outside the network.
A health plan that utilizes a designated group, or network of doctors, hospitals, labs and other providers to provide healthcare services to members. See health plan product descriptions. To receive benefits, the member must first see his/her Primary Care Physician for care or for a referral, except in the case of an emergency. The memberâ€(tm)s choice of providers is restricted to those in the network. Find an Optima Health participating provider.
A group health care plan that provides a full range of health care services to its members. Members of an HMO must typically receive all of their medical care form health care providers in the HMO network, coordinated by a primary care physician. All visits, prescriptions and other care must be cleared by the HMO in order to be covered. A primary physician within the HMO handles referrals. It is similar to an HCO, but care is paid for in advance in the form of a scheduled fee, rather than as care is incurred.
A network of doctors and hospitals that offers services. Except in an emergency, if you use doctors and hospitals that are not in your HMOâ€(tm)s network, no benefits are payable. You must select a Primary Care Physician to coordinate all your care.
A legal corporation that offers health insurance and medical care. HMOs provide a wide range of comprehensive health-care services for a specified group at a fixed, periodic rate. They can be sponsored by the government, medical schools, hospitals, employers, labor unions, consumer groups, insurance companies and hospital-medical plans.
A type of health care program in which enrollees receive benefits when they obtain services that are provided or authorized by selected providers, usually with a primary care physician "gatekeeper." In general, enrollees do not receive coverage for the services of providers who are not in the HMO network, except for emergency services.
A health care insurance plan that provides participants with comprehensive coverage of health care services performed by a selected network of health care providers for a fixed monthly premium. Coverage is available in a defined geographic area (called the service area) to participants who agree to obtain services from network providers. HMOs are unique because they coordinate the financing of health care with the delivery of health care. HMOs emphasize prevention and early detection of illness.
A form of health insurance. An HMO is an organization of health care professionals that provide health care services to members on a prepaid basis.
An organization that provides a wide range of comprehensive health care services through a designated group, or network of doctors, hospitals, labs and other providers. When you join an HMO, you select a Primary Care Physician (PCP) from its staff or from a list of PCPs. Your Primary Care Physician is responsible for coordinating all of your medical care. Referrals to specialists and hospital admissions are arranged by your Primary Care Physician or the HMO company. There are two basic types of HMOs – Staff Model HMOs and Network HMOs. A HMO can be a mixture of the two types. In the staff model HMO, a group of physicians is employed directly by the HMO and practice from a facility that is provided by the HMO. In other HMOs, an independent network of physicians is recruited and contracted by the HMO and practice from health facilities not provided by the HMO.
A health plan that offers prepaid, comprehensive health coverage for both hospital and physician services; members are required to use participating providers and are enrolled for specified periods of time.
A type of Health Benefit Plan under which the Members are required to receive care through a specific group of participating doctors and hospitals in order to receive Benefits.
An organization that provides for wide comprehensive health care services for a specific group at a fixed periodic payment.
nbspPrepaid health plans. You pay a monthly premium and the HMO covers your doctors' visits, hospital stays, emergency care, surgery, checkups, lab tests, x-rays, and therapy. You must use the doctors and hospitals designated by the HMO. You must have a referral from your Primary Care Physician.
An organization that provides a wide range of comprehensive health care services for a specified group of enrollees for a fixed, prepaid premium. There are several models of HMOs: Group Model, Individual Practice Association (IPA), Staff Model and Network Model.
An HMO is a formally organized system that integrates the delivery and financing of health care services.
A health plan that arranges or provides health care services to consumers in exchange for a fixed, prepaid monthly premium. HMOs usually use designated doctors or hospitals, and assume the costs of medical treatments that are higher than the consumers' basic fees and co-payments.
An organization set up and operated to provide health services under a pre-paid or Capitated arrangement; monthly fees to the HMO remain the same regardless of the types or levels of service provided.
A health care plan where all medical services are provided by an organization of health care providers, hospitals, etc. Individuals covered in the HMO must use the providers authorized except in emergencies. A primary care physician (PCP) is appointed, and enrollees must see their PCP unless an authorized referral is made to specialists with the HMO. The advantage of an HMO is that there are no deductibles and normally only requires a small copayment for each medical encounter.
A type of service provider that arranges for both health care services and payment for those services. Requires members to pay a pre-set monthly fee covering a broad range of services rather than payment for individual services. Members must use medical practitioners and facilities approved by the HMO, usually at a location the HMO owns and operates and using medical personnel employed by the HMO. HMOs may contract with Medicare to offer Medicare beneficiaries all services covered by fee-for-service Medicare. When a Medicare beneficiary joins an HMO, he or she must usually “sign over” their Medicare benefits to that HMO.
A health care plan that manages and administers coverage of comprehensive health services. A personal care physician provides your care and refers you to specialists when necessary.
An organization that provides health care services to a specific group of people for a fixed periodic prepayment.
A company that offers health plans that provide medical care from an approved network of providers, at a set fee per visit. You must see a provider within the network, or the HMO may not pay for the service.
The HMO arranges for, or contracts with, a variety of health care providers to deliver a range of services to consumers who make up its membership. All HMOs employ managed care strategies that emphasize prevention, detection and treatment of illness. HMOs use primary care physicians as the coordinator of patient care needs. An HMO may offer consumers an HMO plan or POS plan. (See health maintenance organization plan and point of service plan.)
A health insurer or provider that offers comprehensive services on a prepaid basis. The HMO contracts or directly employs physicians to serve as its network. Physicians are paid a salary, reduced fees, or capitated rate for services. Patient choice is limited to contracted physicians to a varying degree depending on the type of organization. Types of HMO models: Group Model - contract with medical groups for services. IPA Model - contract with an IPA that in turn contracts with individual physicians. Staff Model - a health care model that employs physicians to provide health care to its members. All premiums and other revenues accrue to the HMO which compensates physicians by salary and incentive programs. Direct Contract Model - contracts directly with individual physicians. Mixed Model - members get options ranging from staff to IPA models. Network Model HMO - contracts with more than one physician group, and may contract with single and multi-specialty groups. Open-Ended HMO - a product that allows members to use physicians outside the plan in exchange for additional personal liability in the form of a deductible, coinsurance, or copayment.
A federal act that protects people who change jobs, are self-employed or who have pre-existing medical conditions. HIPAA standardizes an approach to the continuation of healthcare benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those benefits offered to employees in large group plans. The act also contains provisions designed to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status.
A kind of health insurance plan. HMOs usually limit coverage to care from doctors who work for or contract with the HMO. They generally do not require deductibles, but often do charge a small fee, called a co-payment, for services like doctor visits or prescriptions.
an organization that provides health care for a monthly payment set in advance. In a traditional HMO, doctors and other providers are salaried employees and the facilities are owned by the organization. In recent years, however, other forms of HMOs have sprung up that contract with doctors and hospitals to care for members at set, negotiated fees. Many HMOs are hybrids, offering both kinds of care to members. Return to Menu
A medical plan providing comprehensive medical benefits, including preventive care, when you agree to use a select group of network providers. Generally, all care is directed by your chosen Primary Care Physician (PCP) who will refer you to a specialist if medically appropriate.
A medical plan that offers services through specific physicians, hospitals, and other health care professionals. To receive HMO plan benefits, you must use participating HMO doctors and facilities.
is the most common form of managed care. All health services are delivered and paid for through one organization, often under one roof. An HMO requires its participants to use only certain health providers and hospitals, usually those within its own network.
a group health insurance plan offering prepaid medical care to its members
Participants receive medical services from a specified list of in-network providers. The services are contracted and access to speciality care is authorized by a primary care physician.
A type of managed care plan in which a group of doctors, hospitals, and other health care providers agree to deliver health care for a set reimbursement every month. The plan helps coordinate the health care with the individual and the providers that participate in the health plan. If an individual is enrolled in an HMO, he or she generally receives care from the providers in the HMO's network.
A health plan that provides care through contracted or employed physicians and hospitals located in particular geographic or service areas. HMOs emphasize prevention and early detection of illness. Your eligibility to enroll in an HMO is determined by where you live or, in some plans, where you work.
HMOs are also known as managed care plans. These plans typically offer a full selection of health-care benefits, including routine physicals and vision examinations, at the most affordable premiums. HMOs have a smaller selection of physicians. A primary care provider (PCP) is required to coordinate all your health-care needs.
An HMO provides members, through a network of selected physicians and hospitals, a defined set of comprehensive benefits in exchange for a prepaid premium. There are generally no deductibles, small co-payments, and no claims to file. The HMO provides no reimbursement (or a reduced amount) for non-emergency care with a physician or hospital outside of the network. There are several types of HMOs: Group Model, Staff Model, Independent Practice Association (IPA), and Point of Service Plan (POS).
An HMO is a type of health plan in which a member of the plan pays for the care on a copayment basis. As long as the member complies with the provisions of the plan (generally one must first visit a predesignated doctor or clinic in order to obtain care at the discretion of the HMO), there are no other charges for the health care services.
A form of health insurance in which members prepay a premium for the HMO's health services. This generally includes inpatient and ambulatory care. For the patient, it means reduced out-of-pocket costs (i.e., no deductible), no paperwork (i.e., insurance forms), and only a small co-payment for each office visit to cover the paperwork handled by the HMO. There are several different types of HMOs.
A type of health plan that provides health care in return for set monthly payments. Most HMOs provide care through a network of doctors, hospitals and other medical professionals that members must use in order to be covered for care. For the patient, it means reduced out-of-pocket costs (i.e., no deductible), no paperwork (i.e., insurance forms), and only a small copayment for each office visit or prescription.
A health care system that assumes or shares both the financial risks and the delivery risks associated with providing access to in-network medical services to members in a particular geographic area, usually in return for a fixed, prepaid fee.
A health care plan that provides comprehensive medical care for a fixed annual fee in a specific geographic area. With the exception of emergency care outside the HMO’s service area, most services must be provided by the HMO’s doctors, hospitals and other providers to be covered under the HMO plan. Physicians and other providers are paid a salary or have a contract with the HMO to provide services.
An entity with four essential attributes: (1) an organized health care system in a defined geographic area that accepts the responsibility to provide or otherwise ensure the delivery of (2) an agreed-upon set of basic and supplemental health maintenance, prevention, treatment, and rehabilitation services to (3) a voluntarily enrolled group of persons, and (4) for which services the entity is reimbursed through a predetermined fixed periodic prepayment made by, or on behalf of, each person or family unit enrolled. Six types of HMO models have been defined
The oldest form of managed health care. In exchange for a monthly fee, HMOs offer members a comprehensive range of health services, usually including preventive medical care.
An organization providing health care for a geographic area which accepts responsibility for delivering an agreed upon set of services to enrolled members.
An organization that provides, or arranges coverage of health care services for a group of patients. Employer-based HMO coverage is generally paid on a capitated basis for a fixed premium.
A managed care plan that both finances health care services for its subscribers on a prepayment basis and organizes and provides health care services directly through its own employed or contracted health care providers.
( Related information) A type of managed care plan that acts as both insurer and provider of a comprehensive set of health care services to an enrolled population. Services are furnished through a network of providers.
A managed care plan that combines the functions of insurer and provider of care, giving most necessary care for a prepaid fee and placing an emphasis on prevention and careful assessment of medical necessity.
A system for providing comprehensive prepaid health care in which providers deliver health services to a group of subscribers at a predetermined cost.
An alternative to commercial insurance that stresses preventive care, early diagnosis and treatment on an outpatient basis. HMOs are licensed by the state to provide care for enrollees by contracting with specific health care providers to provide specified benefits. Many HMOs require enrollees to see a particular primary care physician (PCP) who will refer them to a specialist if deemed necessary.
The health maintenance organization (HMO) is a comprehensive prepaid system of health care with emphasis on the prevention and early detection of disease and continuity of care.
A managed care system that provides services to members through a network of physicians, hospitals, and other health care providers. HMOs eliminate the need to file claims in most cases by allowing members to "prepay" through monthly premiums and copayments made as services are delivered.
An organization that offers pre-paid, comprehensive healthcare coverage to members for hospital physician services and ancillary services. Medical care and services must be received from participating providers. When care is rendered by participating providers, members are usually only charged a small co-payment or fee for office visits and other medical services. Benefits are generally not available for non-emergency services obtained from non-participating providers.
An organization which arranges a wide spectrum of health care services which commonly include hospital care, physicians' services and many other kinds of health care services with an emphasis on preventive care.
A health care organization that, in return for prospective per capita payments, acts as both insurer and provider of comprehensive but specified medical services.
An organization that provides a wide range of comprehensive health care services for a specified group at a fixed periodic payment. The HMO can be contracted with and sponsored by the government, medical schools, hospitals, employers, labor unions, consumer groups, insurance companies, and hospital-medical plans.
A legal entity that accepts responsibility and financial risk for providing specified services to a defined population during a defined period of time at a fixed price. An organized system of health care delivery that provides comprehensive care to enrollees through designated providers. Enrollees are generally assessed a monthly payment for health care services and may be required to remain in the program for a specified amount of time.
An organization that ,through a coordinated system of health care, provides or assures the delivery of an agreed upon set of comprehensive health maintenance and treatment services for an enrolled group of persons through a predetermined periodic fixed prepayment.
A third party, usually a legal entity, which arranges payment for the provision of basic and supplemental health services to its members from a network of independently contracted providers and facilities on a prepaid or reduced fee basis. Members are required to select a primary care physician to provide routine care, and provide referrals for specialty and hospital services when appropriate.
A managed care health plan that provides services through a fixed network of health care providers who provide comprehensive health care coverage to enrolled members exclusively through the network, with some copayments. All care is provided through a network of providers (primary care physicians, specialists, ancillary service providers, and hospitals).
Prepaid health plans that work with a network of hospitals and doctors to provide a wide range of health services to their members. For a monthly premium, the HMO covers your doctor visits, hospital stays, emergency care, surgery, checkups, lab tests, x-rays, and therapy. You are required to use the doctors and hospitals designated by the HMO. There are three types of HMOs, which are called group model, staff model, and independent practice associations (IPA).
Organization which provides, or ensures the delivery of, a specified set of prevention, treatment, and rehabilitation services to enrollees for a prepaid amount of money.
A prepaid health care plan. The HMO provides a complete set of basic and supplemental health services, including physicians, specialists, inpatient facilities, outpatient facilities and, often, prescription drugs. Subscribers voluntarily enroll and prepay a fixed amount of money at regular intervals.
a network of hospitals, doctors and other medical providers who provide services through an HMO plan.
A pre-paid fee gives members comprehensive health care from pre-selected physicians for a minimal co-payment ($5-$15 co-pay). http://www.iha.org/gloss.htm
A managed care business that organizes health care services for its members. HMOs have three distinct features: Use of primary care providers to coordinate patient care and act as gatekeepers Members required to use designated providers and facilities Payments to providers often involve capitation
An HMO (Health Maintenance Organization) is an organization that provides one type of health insurance. The HMO has agreements with certain doctors and hospitals to give members of the HMO medical care at a reduced cost. An HMO will give you a list of doctors, and you must choose one. With some HMOs, you will pay nothing when you visit a doctor. With other HMOs, you may have to pay a copayment.
Provider and insurer that accepts full risk capitation and aims, among other things, to be more efficient by emphasizing prevention and utilizing case managment services. All | | | | | | | | | | | | | | | | | | | | | | | | | | | Other Glossary V1.5 Polls As of August 25th 2005 are you visiting this site as a..... Family member? RT? RN? PT? OT? ST? Case Manager? MD? Patient? Clergy? Social Worker? Other? Statistics since Febuary 2005
An organization that provides a wide range of comprehensive health care services for a specified group at a fixed payment. Hospitals, employers, labor unions, consumer groups, insurance companies, can sponsor the HMO and hospital-medical plans.
An organization set up and operated to provide health services according to applicable federal or state HMO laws.
HMOs offer prepaid, comprehensive health coverage for both hospital and physician services. An HMO contracts with health care providers, e.g. physicians, hospitals, and other health professionals, and members are required to use participating providers for all health services. Members are enrolled for a specified period of time. Model types include staff, group practice, network and IPA.
An entity that provides, offers or arranges for coverage of designated health services needed by members for a fixed, prepaid premium. There are three basic models of HMOs: group model, individual practice association (IPA), and staff model.
Prepaid group health insurance plan that entitles members to services of participating physicians, hospitals, and clinics. Emphasis is on preventative medicine. Members of the HMO pay a flat periodic fee (usually deducted from each paycheck.
A managed care plan that contracts with a group of physicians, other health care professionals and hospitals (known as a network) to care for its patients (known as members). Members usually must select a primary care physician from the network and call or see this doctor first for all medical care.
An organization that arranges for a network of physicians, health care practitioners and facilities to provide a wide spectrum of health care services to members covered under contracts issued by the HMO. Our HMOs include: MD-Individual Practice Association, Inc. (MD IPA), Optimum Choice, Inc.(OCI) and Optimum Choice of the Carolinas, Inc. (OCCI).
A comprehensive health care financing and delivery organization that provides or arranges for provision of covered health care services to a specified group of enrollees, at a fixed periodic payment, through a panel of providers. Historically, four types of HMO models have been common: 1) staff model in which physicians are salaried employees of the HMO; 2) group model, which contracts with multi-specialty physician group practices; 3) IPA model, which contracts with Independent Practice Associations (IPA), which, in turn, contract with independent physicians who practice in their own offices; 4) network model, which contracts with two or more independent group practices and/or IPAs. The HMO can be sponsored by the government, medical schools, hospitals, employers, labor unions, consumer groups, insurance companies, and hospital medical plans.
A health plan that provides care through a network of physicians and hospitals located in particular geographic or service areas. HMOs emphasize prevention and early detections. Your eligibility to enroll in an HMO is determined by where you live or, in some plans, where you work. Some HMOs have agreements with providers in other service areas for non-emergency care if you travel and are away from home for extended periods. The HMO pays for all covered services as long as you use the doctors and providers in the HMO network. You may have to pay something when you get care, for example, a $10 copayment per office visit. Most HMOs ask you to choose a doctor or clinic to be your primary care provider, or PCP. Your PCP takes care of most of your medical needs. In many HMOs, you must get permission or a referral from your PCP in order to see other providers in the network. Care received from a non-network provider, other than emergency care, is not covered.
An organization providing comprehensive health care services for a fixed, prepaid premium. Most HMOs require that you use physicians within their network. Oftentimes, you are required to choose your primary care physician who monitors your health and directs most courses of your treatment. HMOs use managed care techniques.
An HMO is a health plan to which you pay a fixed premium for an assortment of medical services, usually including primary and preventive care. The primary purpose of an HMO is to coordinate care so as to eliminate unnecessary care and costs. HMOs typically have co-pays rather than cost shares.
Managed care health insurance with an emphasis is on preventive care. The "subscribers" can attend classes on topics such as how to stop smoking, weight loss, etc.
Health plan in which members are required to use a network of providers for a specific time period.
The term used to describe payer organizations that form a network of physicians and hospitals, and contract with them for lower rates on patient care. HMOs focus on preventive care and maintaining health, in addition to treating illnesses. Primary care physicians (PCPs) are generally used as gatekeepers to direct patients to appropriate, cost-effective care. Obtaining care without a PCP's referral, or obtaining care from a non-network provider, usually results in nonpayment for services by the HMO.
A health care plan that combines the financing and delivery of health care to provide comprehensive health care services for subscribing members in a particular geographic area in exchange for a prepaid fee.
An organization that provides health care in return for pre-set monthly payments. Most HMOs provide care through a network of doctors, hospitals and other medical professionals that their members must use in order to be covered for that care.
Prepaid group health insurance plan that entitles members to services of participating physicians, hospitals and clinics. Emphasis is on preventative medicine, and members must use contracted health-care providers.
A pre-paid medical group practice plan that provides a comprehensive predetermined medical care benefit package in a specified geographical location.
also referred to as managed care plans. The HMOs were designed to control spiraling health care costs while maintaining quality care and services. Most HMOs prepay providers for an enrolled group of members, assign members to primary care physicians, and arrange comprehensive benefits through a more limited provider panel. Copayments are often used in the HMO model as the cost- sharing method for the patient.
A type of managed care plan where a beneficiary's "primary care physician" coordinates and controls access to care. The beneficiary must receive medical services from an approved network of doctors, hospitals, skilled nursing facilities, and other providers included in the plan.
An organized system for providing comprehensive prepaid health care. HMOs provide care in a defined geographic area; provide or ensure delivery of an agreed-upon set of basic and supplemental health maintenance and treatment services; provide care to a voluntarily enrolled group of persons; require their enrollees to use the services of designated providers; and receive a predetermined, fixed, periodic prepayment made by or on behalf of the member. HMOs are licensed and reviewed by government agencies such as Agency for Health Care Administration (AHCA) to ensure compliance with state and/or federal regulations.
A type of Health Benefit Plan under which the Members receive all medical services through a specific group of Participating Providers.
Prepaid health plans that provide a range of services in return for fixed monthly premiums or other payment methods. Virtually any organization can sponsor an HMO, including the government, medical schools, hospitals, employers, labor unions, and insurance companies.
A type of prepaid health care plan consisting of physicians, hospitals, and other medical service providers that offers a range of health care services for a fixed fee paid in advance. Federal law requires employers with 25 or more employees to offer HMOs as an alternative to traditional health insurance plans in local areas where HMOs are available. HMOs may contract with Medicare to offer Medicare beneficiaries all services covered by fee-for-service Medicare.
A popular form of managed care. HMOs offer a prepaid system of health coverage where the providers are usually paid under the capitation system. There are dental HMOs and medical HMOs. HMOs tend to be a very restrictive form of managed care. This is because one of their primary functions is to control the costs of health care by controlling the usage of health care resources. The main control tool in accomplishing this is the use of gatekeepers. Members are usually to having to use the HMOs providers. Kaiser is one of the larger and most well known HMOs.
A popular form of managed care. They offer a prepaid system of coverage where the providers are usually paid under the capitation system. There are medical and dental HMOs. HMOs are a very restrictive form of managed care. This is mainly due to the fact that one of their primary functions is to control the costs of health care by controlling the usage of health care resources. The main control tool in accomplishing this is the use of gatekeepers. Members are typically restricted to using the HMOs providers. Kaiser is one of the largest and most well known HMOs.
A managed care plan which stresses preventative care and offers the HMO the same premium whether or not a patient needs help. This encourages patients to keep up with medical problems instead of letting unknowingly potentially serious conditions go too far.
An organization engaged in providing managed care and assuming the risk for health related benefits.
HMOâ€(tm)s provide health care services for a fixed fee and a low co-payment for services. You are covered only for treatment approved by the HMO and you must use HMO physicians and facilities (refer to page 13).
A form of health insurance in which members prepay a premium for the HMO's health services. The HMO is the legal entity that assumes responsibility for health care services and for the cost of care. There are different models: staff, group, IPA, hybrid, network, and POS. The Staff Model HMO is an organization that employs physicians who are salaried. The Group Model is similar except the physicians are organized as a group which contracts with the HMO. A Network Model HMO consists of a network of physicians who work in their offices and may not work exclusively for the HMO.
A health care system that assumes or shares both the financial risks and the delivery risks associated with providing comprehensive medical services to a voluntarily enrolled population in a particular geographic area, usually in return for a fixed, prepaid fee.
Offers comprehensive health benefits for members who are enrolled on a group basis and who pay a fixed premium in advance for services provided by participating physicians and hospitals.
an entity that provides, offers or arranges for coverage of health services needed by plan members for a fixed, prepaid amount of money.
A prepaid health plan that provides comprehensive benefits using certain health care professionals, at times in specified locations, generally within certain geographic areas.
A managed care plan that provides health care to plan members on a pre-paid basis. In most HMOs, you must get all your care from the doctors and hospitals that are part of the plan's network. Usually a primary care doctor coordinates all of your care and refers you to specialists.
One-stop healthcare organization which provides for all medical needs and makes referrals for any specialized care required but not available within the main structure of the organization. Most HMO's consists of a large group of healthcare professionals who can provide services in a variety of general areas. The overall operation is managed like a business and the emphasis is on preventive healthcare measures.
An organization of health care providers that provides services for a specified group at a fixed cost.
HMOs are the oldest form of managed care plan. HMOs offer members a range of health benefits, including preventive care, for a set monthly fee. There are many kinds of HMOs. If doctors are employees of the health plan and you visit them at central medical offices or clinics, it is a staff or group model HMO. Other HMOs contract with physician groups or individual doctors who have private offices. These are called individual practice associations (IPAs) or networks. HMOs will give you a list of doctors from which to choose a primary care doctor. This doctor coordinates your care, which means that generally you must contact him or her to be referred to a specialist. With some HMOs, you will pay nothing when you visit doctors. With other HMOs there may be a co-payment, like $5 or $10, for various services. If you belong to an HMO, the plan only covers the cost of charges for doctors in that HMO. If you go outside the HMO, you will pay the bill. This is not the case with point-of-service plans.
Prepaid medical plan in which members agree to use a specific network of providers.
An entity that provides a wide range of health services for a fixed, prepaid premium. The HMO may provide all services or contract with other sources for additional services.
The HMO plan is administered by HMO Blue (Blue Cross Blue Shield). The member must choose a Primary Care Physician from a list of network doctors in order to receive benefits. A referral is required to see a network specialist and for network hospitals. A co-payment is due at the time covered services are rendered.
An organization that, for a prepaid fee, provides a comprehensive range of health maintenance and treatment services (including hospitalization, preventive care, diagnosis, and nursing).
Managed care plan that provides services for a fixed period on a prepaid basis.
For most people age 65 and older, a type of Medicare managed care plan where a group of doctors, hospitals and other health care providers agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. In an HMO, you usually must get all of your care from the providers that are part of the plan; if you use providers that are outside your HMO plan, you will pay for their services out of your own pocket.
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A Health Maintenance Organization (HMO) is a type of Managed Care Organization (MCO) that provides a form of health insurance coverage in the United States that is fulfilled through hospitals, doctors, and other providers with which the HMO has a contract. Unlike traditional indemnity insurance, care provided in an HMO generally follows a set of care guidelines provided through the HMO's network of providers. Under this model, providers contract with an HMO to receive more patients and in return usually agree to provide services at a discount.
See Part II, 45 CFR 160.103.