HMO's And Managed Care For People With Diabetes

Find out how HMO's, PPOs, etc... can affect diabetes and your ability to get good health care for you or a loved one...

What is an EPO, PPO, or HMO?   The abbreviations associated with managed care can be quite confusing.  The term "managed care" is a general term used for an organized group of healh-care providers.  Managed care plans include health maintenance organizations (HMO's), Preferred Provider Organizations (PPO's), and exclusive provider organizations (EPO's).  One big advantage to a managed care plan is that the costs are usually lower to you.  Two drawbacks might be that you can't always visit the doctor of your choice or you may need to receive a referral (permission) to see a specialist.

In an HMO, most of the cost for medical care is covered by a fee paid by you or your employer.  You may also pay a small co-payment after each visit.

These are different types of HMO's:

Staff HMO - your medical care is provided by people who work in a clinic or health center owned by the HMO.  You get all your medical care in one place.

Group HMO - you get your medical care from providers who are part of a physician group contracted by the HMO.  The physician group may work at one or more locations

Independent or Individual Practice Association (IPA) - your medical care is from providers who are under contract with an HMO.  They may also provide fee-for-service care.  You visit them at their private offices.

Network HMO - you get your medical care from providers who belong to any of several physician groups contracted by the HMO.  The physician groups work at many locations.

A PPO (Preferred Provider Organization) is a list of health care providers.  This list is prepared and provided by an insurance company.  The providers on the list are "preferred" because they have agreed to discount their fees.  They are paid by the insurer and by a small co-payment from you.  You may also have to pay a small deductible.  If you choose to go to a provider who is out of the PPO you will pay more.

An EPO (Exclusive Provider Organization) is like a PPO but if you choose to go to a provider who isn't in the EPO you pay for the total visit.

If you go to a provider outside of the staff HMO, group HMO, or network HMO the cost for that care is usually not covered.  If you go to a provider outside of an IPA, the cost of your medical care is not covered unless your IPA doctor refers you to the outside provider.

Again, memorizing all these abbreviations and their definitions might be confusing and take awhile but it's good information to keep on hand.