HMO Definition

Health Definitions: HMO

HMO Definition: Definition: HMO

A HMO Definition: A Medicare HMO is an HMO that has contracted with the federal government under the Medicare + Choice program to provide health benefits to persons eligible for Medicare that choose to enroll in the HMO, instead of receiving their benefits and care through the traditional fee for service Medicare program.

HMO stands for Health Maintenance Organization. It is an organization of healthcare providers (e.g. doctors and hospitals) that have contracted with an insurance company to offer their services at a fixed price.

HMO plans tend to be very restrictive and have many rules. You will be required to select a primary care physician, who manages all aspects of your healthcare. The primary care physician must be a member of the HMO, so you may need to switch doctors if the one you are currently seeing is not in the network. If you need to see a specialist, you will be required to see your primary care physician first to obtain a referral.
  • Managed care is a complex system that involves the active coordination of, and the arrangement for, the provision of health services and coverage of health benefits.

  • The most common types of Managed Care Organizations (MCOs) include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) and Exclusive Provider Organizations (EPOs.)

Managed care usually involves three key components:

  • oversight of the medical care given;

  • contractual relationships and

  • organization of the providers giving care; and the covered benefits tied to managed care rules.

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