A health care system that assumes both
the financial risks associated with providing comprehensive medical services
(insurance and service risk) and the responsibility for health care delivery in a
particular geographic area to HMO members, usually in return for a fixed, prepaid
fee. Financial risk may be shared with the providers participating in the HMO.
the financial risks associated with providing comprehensive medical services
(insurance and service risk) and the responsibility for health care delivery in a
particular geographic area to HMO members, usually in return for a fixed, prepaid
fee. Financial risk may be shared with the providers participating in the HMO.
Group Model HMO - An HMO that contracts with a single multi-specialty
medical group to provide care to the HMO’s membership. The group practice
may work exclusively with the HMO, or it may provide services to non-HMO
patients as well. The HMO pays the medical group a negotiated, per capita rate,
which the group distributes among its physicians, usually on a salaried basis.
Staff Model HMO - A type of closed-panel HMO (where patients can receive
services only through a limited number of providers) in which physicians are
employees of the HMO. The physicians see patients in the HMO’s own facilities.
¨ Network Model HMO - An HMO model that contracts with multiple physician
groups to provide services to HMO members; may involve large single and multispecialty
groups. The physician groups may provide services to both HMO and
non-HMO plan participants.
¨ Individual Practice Association (IPA) HMO- A type of health care provider
organization composed of a group of independent practicing physicians who
maintain their own offices and band together for the purpose of contracting their
services to HMOs. An IPA may contract with and provide services to both HMO
and non-HMO plan participants.
Point-of-service (POS) plan - A POS plan is an "HMO/PPO" hybrid; sometimes
referred to as an "open-ended" HMO when offered by an HMO. POS plans resemble
HMOs for in-network services.
Services received outside of the network are usually
reimbursed in a manner similar to conventional indemnity plans (e.g., provider
reimbursement based on a fee schedule or usual, customary and reasonable charges).
Physician-hospital organization (PHO) - Alliances between physicians and
hospitals to help providers attain market share, improve bargaining power and reduce
administrative costs. These entities sell their services to managed care organizations
or directly to employers.
reimbursed in a manner similar to conventional indemnity plans (e.g., provider
reimbursement based on a fee schedule or usual, customary and reasonable charges).
Physician-hospital organization (PHO) - Alliances between physicians and
hospitals to help providers attain market share, improve bargaining power and reduce
administrative costs. These entities sell their services to managed care organizations
or directly to employers.