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.

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