Capitation:
A method of paying for medical services on a per-person rather than a
per-procedure basis. Under capitation, an HMO pays a participating
doctor a fixed amount per month for every HMO member he or she takes
care of, regardless of how much or how little care the member receives.
Copayment:
A fixed payment the patient pays each time he or she visits a health
plan clinician or receives a covered service.
Deductible:
More typical in traditional health insurance, a fixed amount the
patient must pay each year before the insurer will begin covering the
cost of care.
Fee-for-service:
The traditional method of paying for medical services. A doctor
charges a fee for each service provided, and the insurer pays all or
part of that fee. Sometimes the patient pays a copayment for each visit
to the doctor.
Health Maintenance Organization (HMO):
An organization that provides health care in return for set monthly
payments. Most HMO's 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.
HMO Model Types:
HMOs come in different forms or "models":
- Staff Model HMO: A type of HMO in which the doctors and other
medical professionals are salaried employees of the HMO, and the clinics
or health centers in which they practice are owned by the HMO.
- Group Model HMO: A model of HMO made up of one or more
physician group practices that are not owned by the HMO, but that
operate as independent partnerships or professional corporations. The
HMO pays the groups at a negotiated rate, and each group is responsible
for paying its doctors and other staff, and for paying for hospital care
or care from outside specialists.
- Independent Practice Association (IPA): IPAs generally
include large numbers of individual private practice physicians who are
paid either a fee or a fixed amount per patient to take care of the
IPA's members.
- Mixed Model HMO: A health plan that includes more than one
form o HMO within a single plan. For instance, a staff model HMO might
also contract with independent physician groups or with individual
private practice physicians.
Managed Care Organization:
An umbrella term for HMOs and all health plans that provides health
care in return for set monthly payments and coordinate care through a
defined network of primary care physicians and hospitals.
Network:
The doctors, clinics, health centers, medical group practices,
hospitals, and other providers that an HMO, PPO, or other managed care
plan has selected and contracted with to care for its members.
Out-of-network:
Not in the HMO's network of selected and approved doctors and
hospitals. HMO members who get care out-of-network (sometimes called
out-of-area) without getting permission from the HMO to do so may have to
pay for all or most of that care themselves. Exceptions are usually made
for extreme emergencies or urgent care needed when traveling from home.
Point-of-Service (POS0 plan:
A type of HMO coverage that allows members to choose to receive
services either from participating HMO providers, or from providers
outside the HMO's network. In-network care is more likely to be fully
covered; for out-of-network care, members pay deductibles and a percentage
of the cost of care, much like traditional health insurance coverage.
Practice Guidelines:
Carefully developed information on diagnosing and treating specific
medical conditions. Practice guidelines, usually based on clinical
literature and expert consensus, are designed to help physicians and
patients make decisions, and to help a health plan evaluate
appropriateness and medical necessity of care.
Preferred Provider Organization (PPO):
A network of doctors and hospitals that provides care at a lower cost
than through traditional insurance. PPO members get better benefits (more
coverage) when they use the PPO's network, and pay higher out-of-pocket
costs when they receive care outside the PPO network.
Preventive care:
Care designed to prevent disease altogether, to detect and treat it
early, or to manage its course most effectively. Examples of preventive
care include immunizations and regular screenings like Pap smears or
cholesterol checks.
Primary care:
Preventive health care and routine medical care that is typically
provided by a doctor trained in internal medicine, pediatrics, or family
practice, or by a nurse, nurse practitioner, or physician assistant.
Primary Care Physician (PCP):
A physician, usually an internist, pediatrician, or family physician,
devoted to the general medical care of patients. Most HMOs require members
to choose a primary care physician, who is then expected to provide or
authorize all care for that patient.
Referral:
A formal process that authorizes an HMO member to get care from a
specialist or hospital. To assure coverage, an HMO patient generally must
get a referral from his or her primary care doctor before seeing a
specialist.
Specialist:
A doctor or other health professional whose training and expertise are
in specific area of medicine, like cardiology or dermatology. Most HMOs
require members to get a referral from their primary care physician before
seeing a specialist
Questions? Please call the Lourdes Physician Referral
Number at 797-0006.