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HMOs Unique Features And Lingo

Medical Group

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A group of doctors or other health care providers.

There are several types of medical groups in use with HMOs:

  • Staff Model
  • Group Practice Model
  • Independent Practice Associations

Staff Model

Under a staff model, doctors are employees of the HMO.  The doctors generally work in a facility owned or leased by the HMO. The doctors only treat members of the HMO.

Kaiser Permanente is the prime example of a staff model HMO.

Group Practice Model

Under a group practice model, rather than have doctors as employees, the HMO contracts with medical groups or individuals through the medical group -- a joint practice of doctors and/or other providers.  Some group practices have hundreds of doctors and many locations. Others have only a few.

When you enroll in an HMO with a group practice model, you may choose to go to any primary care physician in the group. You can also change primary care physicians whenever you want as long as you remain within that medical group.

Although the medical groups are paid on a Capitation basis, it is up to each group in its agreement with its doctors whether each doctor is paid on a fee-for-service basis or capitated. A group may pay all primary care doctors on a capitation basis while the specialists are paid fee-for-service.

Independent Practice Associations ("IPA")

An IPA is a group of physicians in their own private practices that have organized a loose association. The association contracts with the HMO.

The main difference between an IPA and a Group Practice is that with an IPA, when you enroll as a member, you will be required to name your Primary Care Physician  so that the Capitation can go to the right doctor. If you later want to change your Primary Care Physician, you must follow the HMO's procedures.

Just as with a Group Practice, it is up to the group whether the participating doctors are paid on a capitation or fee-for-service basis.

Network Model

The HMO contracts with many groups or doctors and health care facilities to form a network.

Mixed Model

A combination of the above systems. 

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