A type of managed care organization that provides healthcare services through a network of healthcare providers for a fixed monthly premium. HMOs emphasize preventive care and typically require members to select a primary care physician (PCP) who coordinates their healthcare needs.
A healthcare provider, often a general practitioner or family doctor, who serves as the first point of contact for patients within the HMO network. PCPs manage patients’ overall healthcare needs, refer them to specialists when necessary, and coordinate their care.
A group of healthcare providers, including doctors, hospitals, and other medical facilities, with which the HMO has contracts to provide services to its members at negotiated rates. Members typically receive the highest level of coverage when they use providers within the network.
A fixed amount that members pay out-of-pocket for specific medical services or prescriptions at the time of service. Co-payments are typically lower for services received within the HMO network compared to out-of-network providers.
Healthcare services and interventions aimed at preventing illness, detecting diseases early, and promoting overall wellness. HMOs often prioritize preventive care, including routine screenings, vaccinations, and health education programs, to improve health outcomes and reduce long-term healthcare costs.
A term sometimes used to describe the role of the primary care physician (PCP) in an HMO. PCPs act as gatekeepers by managing and coordinating patients’ healthcare needs, including referrals to specialists and approving necessary medical services.
The process used by HMOs to evaluate the medical necessity and appropriateness of healthcare services, procedures, or treatments before they are provided to members. Utilization review helps control costs and ensure quality care by determining if requested services meet established criteria.
Healthcare providers or facilities that do not have contracts with the HMO. Members may still receive care from out-of-network providers, but they typically incur higher out-of-pocket costs and may need prior authorization from the HMO for non-emergency services.
A specified period during which eligible individuals can enroll in or make changes to their health insurance coverage, including selecting an HMO plan. Open enrollment periods are typically offered annually and may be accompanied by employer-sponsored benefits fairs or educational materials to assist members in making informed choices.
A tax-advantaged savings account available to individuals enrolled in a high-deductible health plan (HDHP), which may be offered alongside HMO options. HSAs allow members to contribute pre-tax funds to cover qualified medical expenses, providing a financial tool for managing healthcare costs and saving for future medical needs.