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HMO Terms Explained

EOC or SPD — Evidence of Coverage or Summary Plan Description (SPD). These documents are the most important documents you will receive from your HMO. Make sure you read them and know where they are. Evidence of Coverage is a complete document, while a Summary Plan Description simply summarizes your contract with the health plan. Your EOC or SPD explains your health care benefits, any limits to your coverage, the health plan's policies and procedures and what costs you will have to pay.

FFS — Fee for Service. This is the "traditional" form of health insurance, where you (or your employer) pay a monthly premium to the insurance company, and your doctor is paid by the insurance company for any service he or she provides.

HMO — Health Maintenance Organization. This is a broad term that, in general, refers to any organized plan other than a traditional health insurance company that provides for your health care. Some plans are very tightly structured so that all care is provided by the HMO's employees in the HMO's hospitals or clinics, while other plans are cooperative agreements among independent doctors, hospitals and other health care providers.

IPA or Medical Group — IPA stands for Independent Practice Association, which is a group of independent doctors who work together to provide care and negotiate how much they will be paid by an HMO. Medical Groups are generally more highly structured groups of doctors, but they have banded together for the same reason groups of doctors join IPAs - to provide care to patients and negotiate payment rates with HMOs.

It is critically important for patients to understand whether the organization they are dealing with is the HMO itself, or the Medical Group or IPA. Many times, the HMO will delegate authority to the group of physicians actually providing care, which means that the HMO itself is not claiming responsibility for the final decision. Other times, however, the HMO is the final decision maker. Patients should understand who has the final say - the HMO or the physician group.

PCP — The Primary Care Provider is the doctor who is primarily in charge of your care. If you need to see a specialist, or need lab tests, many HMOs require your Primary Care Provider to approve them. When you first sign up with an HMO, you will be asked to choose a PCP. If you don't, some plans will assign one to you. In either case, you can always change your PCP if you want to. This doctor will be in charge of your health care, so it is important to find one you feel comfortable with. It is generally best to try and get to know your doctor over a couple of visits, but if you are unhappy for any reason, find out from your HMO what you need to do to choose another PCP. In any event make sure you know who your PCP is, if your HMO requires you to have one.

PPO — Preferred Provider Organization. This is a particular kind of HMO which allows patients a greater selection of doctors. The cost to the patient depends on whether the patient goes to one of the plan's "preferred" providers (in which case the patient pays a lower cost) or some other health care provider (in which case the patient pays a higher cost).

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