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Capitation - Doctors automatically receive a certain payment per person per month rather
than being compensated for each procedure.
Copayment - A set fee paid by the patient for an office visit or other covered service
(generally $5 to $15).
Deductible - In traditional health insurance, the amount a patient must pay out of his
own pocket before coverage kicks in.
The ABCs of Managed Care
Fee-for-service - The traditional form of payment, in which the patient
or insurer pays for each doctor visit or service provided.
Group Model HMO - Care is provided by a network of physician group practices
that have agreed to accept a certain level of payment.
Health Maintenance Organization (HMO) - An organization that finances,
organizes, and provides health care using the principles of managed care.
Independent Practice Association (IPA) model HMO - A type of HMO in which
doctors in private practice are paid to care for health plan members.
Managed-care Organization - An umbrella term for any organization that sets
policies and procedures for controlling the cost and delivery of health
care.
Mixed Model HMO - A plan that includes more than one model; for example
a staff model HMO might also contract with some group practices or individual
physicians to provide care in certain geographic areas.
Network - Doctors, hospitals, and other providers that have contracted with
an HMO to care for its members.
Point-of-service (POS) plan - Coverage that allows members to use out-of-network
services, so long as they pay a deductible and part of the cost.
Preferred Provider Organization (PPO) - A network of physicians and hospitals
that contract with an insurance company to care for its policyholders at
discounted fees.
Staff model HMO - All care is delivered at HMO-run facilities by salaried
staff doctors; also called a "closed panel" plan.
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