Capitation:
A method of paying for medical services on a per-person rather
than a per-procedure basis. Under capitation, a Health Maintenance
Organization (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 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.
Health Maintenance Organization (HMO) Model Types:
HMOs come in different forms/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 (POS) 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 physician 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 1-877-9Lourdes.
