Practical Law Glossary Item w-016-4187 (Approx. 2 pages)
Glossary
Health Maintenance Organization (HMO)
A managed care arrangement that:
Contracts with health providers to furnish medical services to covered participants.
Typically receives a fixed fee for each individual enrolled under the arrangement.
HMO eligibility may be limited to individuals who live or work in a certain geographical area. Participants in an HMO must generally designate a primary care provider that is responsible for furnishing referrals for other health care services, including specialty care. HMOs also typically employ cost-controlling measures (such as preauthorization and utilization review) and may furnish guidelines to providers regarding appropriate levels of care.
HMO usually do not cover services provided by out-of-network providers except for: