MCPR 2005 - Measuring the Quality of Pennsylvania's Commercial HMOs - What Is An HMO?

Most Pennsylvanians receive their health care benefits through their employer or from a government-sponsored program, such as Medicare or Medical Assistance. An HMO is an organized system that provides prepaid health benefits to a defined group of members. Unlike traditional insurers, HMOs typically offer and encourage members to take advantage of a host of educational materials, disease management programs, preventive health services and other initiatives to keep their members healthy. HMO members usually are required to select a Primary Care Physician (PCP) who has the responsibility to coordinate the various health services available to members. HMOs may share financial responsibility with PCPs and other providers for the services provided to members. "Point-of-Service" (POS) options offered by HMOs often combine the structure of HMOs (members select PCPs and usually access non-primary care services through pre-approved referrals) with the flexibility to access services without pre-approved referrals and the option to leave the network of participating providers by paying an additional fee. A "gatekeeper" Preferred Provider Organization (GPPO) product usually requires a patient to select a PCP from a preferred provider panel and to seek referrals from the PCP in order to see a specialist without incurring additional uncovered fees. This report provides information about the health care services received by members of commercial HMOs, POS plans, and GPPO products. A summary of the characteristics of the types of health insurance plans is provided in the following table.

HMO Point-of-Service GPPO Fee-for-Service
Can you get covered services from providers not in the network? No Yes, for an additional charge Yes, for an additional charge Yes
Do you have a lot of paperwork? No claim forms No claim forms for in-network care No claim forms for in-network care You need a claim form
Do you need to choose a PCP? Yes Yes Usually, "passive" gatekeeper products do not require it No
Do you need a referral from your PCP to go to a specialist? Yes Usually Yes, to receive the highest level of coverage No

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