Managed Care:
Health care systems that integrate the
financing and delivery of appropriate
health care services to covered
individuals by arrangements with selected
providers to furnish a comprehensive set
of health care services, explicit
standards for selection of health care
providers, formal programs for ongoing
quality assurance and utilization review,
and significant financial incentives for
members to use providers and procedures
associated with the plan.
PPO:
Preferred Provider
Organization (PPO) - A system in which a
payer negotiates lower prices with certain
doctors and hospitals. Patients who go to
a preferred provider get a higher benefit,
for example-- 90 percent or 100 percent
coverage of their costs -- than patients
who go
outside the network.
HMO:
Health Maintenance
Organization (HMO) - A legal corporation
that offers health insurance and medical
care. HMOs typically offer a range of
health care services at a fixed price.
Types of HMOs include the following:
- Staff Model --
Organization owns its clinics and
employs its docs.
- Group Model --
Contract with medical groups for
services.
- IPA Model -- Contract
with an IPA that in turn contracts
with individual physicians.
- Direct Contract Model
-- Contracts directly with individual
physicians.
- Mixed Model --
Members get options ranging from staff
to IPA models.
POS:
Point of Service Plan
(POS) - An HMO plan which allows the
member to pay little or nothing if they
stay within the established HMO delivery
system, but permits member to choose and
receive services from an outside doctor,
any time, if they are willing to pay
higher copayments, deductibles and
possibly monthly premiums. Also called an
open-ended plan.
EPO:
Exclusive Provider Organization (EPO) - A
health plan in which patients must go to a
participating provider or receive no
benefit. This is a cross between an HMO
and a PPO (See preferred provider
organization). Like a PPO doctors
typically are paid on a fee-for-service
basis and aren't at risk. However,
patients have less freedom to go out of
network than with a PPO.
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