That combination of insurance companies, employer groups, providers of care and government agencies that work together to provide health care to a population.
CCMC Glossary of Terms Related to Healthcare Delivery Systems
Exclusive Provider Organization (EPO): A managed care plan that provides benefits only if care is rendered by providers within a specific network.
Health Maintenance Organization (HMO): An organization that provides or arranges for coverage of designated health services needed by plan members for a fixed prepaid premium. There are four basic models of HMOs: group model, individual practice association (IPA), network model, and staff model. Under the Federal HMO Act an organization must possess the following to call itself an HMO: (1) an organized system for providing healthcare in a geographical area, (2) an agreed-on set of basic and supplemental health maintenance and treatment services, and (3) a voluntarily enrolled group of people.
Integrated Delivery System (IDS): A single organization or group of affiliated organizations that provides a wide spectrum of ambulatory and tertiary care and services. Care may also be provided across various settings of the healthcare continuum.
Preferred Provider Organization (PPO): A program in which contracts are established with providers of medical care. Providers under a PPO contract are referred to as preferred providers. Usually the benefit contract provides significantly better benefits for services received from preferred providers, thus encouraging members to use these providers. Covered persons are generally allowed benefits for nonparticipating provider services, usually on an indemnity basis with significant copayments.
Point-of-Service (POS) Plan: A type of health plan allowing the covered person to choose to receive a service from a participating or a nonparticipating provider, with different benefit levels associated with the use of participating providers. Members usually pay substantially higher costs in terms of increased premiums, deductibles, and coinsurance.
Health Maintenance Organization (HMO): An organization that provides or arranges for coverage of designated health services needed by plan members for a fixed prepaid premium. There are four basic models of HMOs: group model, individual practice association (IPA), network model, and staff model. Under the Federal HMO Act an organization must possess the following to call itself an HMO: (1) an organized system for providing healthcare in a geographical area, (2) an agreed-on set of basic and supplemental health maintenance and treatment services, and (3) a voluntarily enrolled group of people.
Integrated Delivery System (IDS): A single organization or group of affiliated organizations that provides a wide spectrum of ambulatory and tertiary care and services. Care may also be provided across various settings of the healthcare continuum.
Preferred Provider Organization (PPO): A program in which contracts are established with providers of medical care. Providers under a PPO contract are referred to as preferred providers. Usually the benefit contract provides significantly better benefits for services received from preferred providers, thus encouraging members to use these providers. Covered persons are generally allowed benefits for nonparticipating provider services, usually on an indemnity basis with significant copayments.
Point-of-Service (POS) Plan: A type of health plan allowing the covered person to choose to receive a service from a participating or a nonparticipating provider, with different benefit levels associated with the use of participating providers. Members usually pay substantially higher costs in terms of increased premiums, deductibles, and coinsurance.
Exclusive Provider Organization (EPO)
EPO’s have a network of providers who have agreed to provide care for the members at a discounted rate. If the patient chooses to go outside the network, there is no reimbursement.
Health Maintenance Organization (HMO)
HMO’s often use the Primary Care Physician (PCP) as the “gatekeeper”. A patient receives all primary and preventative care from the PCP. Any care needs outside the PCP’s scope of practice would be referred out and coordinated by the PCP. Any care, other than emergency care, not coordinated through the PCP would not be covered by the HMO.
4 Types of HMOs
- Group Model HMOs
- Individual Practice Association (IPA) Model HMO
- Network Model HMO
- Staff Model HMO
Integrated delivery system (IDS)
IDS’s are systems of healthcare that provide services across the continuum of care settings. Providers including physicians and hospitals are often owned or aligned with an insurance company. Some of the services provided include primary care, hospital, outpatient, home health and rehabilitation.
Preferred Provider Organization (PPO)
PPO’s contract with providers to dispense care at a discounted rate. The providers with whom they contract are considered “network providers or prefered providers”. If the patient uses a provider that is not part of the network they will have a larger financial responsibility.
Point-of-Service (POS) Plan
The Point-of-Service Plan is a combination of a PPO and HMO. The patient can choose to receive care in network at little or no cost, or to go out of network and have larger out of pocket expenses.
