Glossary of Terms
A-to-Z reference of healthcare terms used on this site. In a future iteration these definitions will be offered as inline tooltips wherever the terms appear in context, so members can hover on a term and read the definition without leaving the page.
- Commercial HMO
- HMOs sell medical insurance to commercial businesses or employer groups. Employer must sign a contract with the HMO which stipulates the standard benefits and options selected for group's employees and premium payable.
- Group Model HMO
- HMOs contract with multi-specialty medical groups of which the physicians are employees, partners or shareholders.
- HMO (Health Maintenance Organization)
- Hybrid health care organizations that combine aspects of insurers with providers. Better able to control costs than can insurance companies and make health care more affordable. Financial risk shared between HMO and their contracted providers through various arrangements (e.g., capitation, per diem rates, fee schedules, case rates, risk pools, discounted FFS payments, outliers)
- IPA (Independent Practice Association)
- An association of independent physicians, or other organization that contracts with independent physicians, that provides services to managed care organizations
- IPA Model HMO
- HMOs contract with an association of private practice physicians; care is provided in private offices of IPA's participating physicians
- Knox-Keene
- The Knox-Keene Health Care Service Plan Act of 1975 and accompanying laws regulate managed care plans
- Network Model HMO
- HMOs contract with several medical groups or IPAs
- Outliers
- Clause which changes the basis of reimbursement back to discounted charges under certain conditions. Establishes a maximum dollar limit per case for which per diem rates apply. If limit is exceeded, payment reverts to discounted charges.
- PCP (Primary Care Physician)
- HMO members required to choose a PCP to serve as their personal doctor. PCPs coordinate services furnished by various providers in complex cases and serve as gatekeepers, limiting access to specialist and hospital services.
- PPO (Preferred Provider Organization)
- Hybrid of HMO and indemnity insurance in which services are completely paid for
- Staff Model HMO
- Employs physicians and other medical staff to provide care to members in HMO-owned clinics/hospitals/pharmacies and other care facilities
Update needed: expand with current regulatory terms relevant to ACA § 1557 (language-access, meaningful-access), Medicare Star Ratings, HEDIS, CAHPS, value-based-care arrangements (MSSP, REACH), and specific California-regulatory terms.