Sandi Hodges

Health Maintenance Organization

A form of health insurance in which its members prepay a premium for the HMO's health services which generally include inpatient and ambulatory care. For the patient, an HMO means reduced out-of-pocket costs (i.e. no deductible), no paperwork (i.e. insurance forms), and only a small copayment for each office visit to cover the paperwork handled by the HMO; (2) A organization of health care personnel and facilities that provides a comprehensive range of health services to an enrolled population for a fixed sum of money paid in advance for a specified period of time. These health services include a wide variety of medical treatments and consults, inpatient and outpatient hospitalization, home health service, ambulance service, and sometimes dental and pharmacy services. The HMO may be organized as a group model, an individual practice association (IPA), a network model or a staff model.

Exclusive Provider Organization

An EPO is a form of PPO, in which patients must visit a caregiver that is specified on its panel of providers (is a participating provider). If a visit to an outside(not participating) provider is made the EPO offers very limited or no coverage for the medical service; (2) While similar to a PPO in that an EPO allows patients to go outside the network for care, if they do so in an EPO, they are required to pay the entire cost of care. An EPO differs from an HMO in that EPO physicians do not receive capitation but instead are reimbursed only for actual services provided; (3) An organization identical to a preferred provider organization except that persons enrolled in the plan are eligible to receive benefits only when they use the services of the contracting providers. No benefits are available when non-contracting providers are used, except in certain emergency situations.

Preferred Provider Organization

A group of physicians and/or hospitals who contract with an employer to provide services to their employees. In a PPO, the patient may got to the physician of his/her choice, even if that physician does not participate in the PPO, but the patient receives care at a lower benefit level.

Point of Service Managed Care Organization

This product may also be called an open-ended HMO and offers a transition product incorporating features of both HMOs and PPOs. Beneficiaries are enrolled in an HMO but have the option to go outside the networks for an additional cost.