Managed Care Organizations

8 Health Care Glossary Items #7

A Preferred Provider Organization (PPO) is a managed care organization. It consists of a network of doctors, hospitals and other health care providers who provide discounted rates to customers of a partnered insurance company. An individual with a PPO health care policy can choose to see any doctor they wish, but they will not receive discounted rates, including lower co-payments, as they would with an in-network provider. The individual is still in control of their health care and can determine which health care providers they will see and when they will see them.

A Health Maintenance Organization (HMO) is also a managed care organization with a network of health care providers partnering with an insurance company. When an individual joins an HMO, they will need to select a primary care physician within the HMO network. This physician will be responsible for coordinating all of an individuals health care needs, including referrals to specialists. Generally, an HMO will not pay any benefits to an out-of-network provider, except in the case of an emergency or when there is no provider within the network that provides a needed service.