ABC's of Managed Care 

To help everyone better understand this booklet, I’ve made up a list of words we use often.

Clinic-based HMOs: A clinic-based HMO has all of its services in one building: your primary care doctor, specialists, urgent care clinic, pharmacy, lab, etc. 

Emergency: A medical emergency is any situation that needs immediate medical attention and seriously threatens your health. See EMERGENCY CARE 

Enrollee: A person enrolled in a managed care program such as an HMO. 

Exemptions: While enrollment in an HMO is required of most Medicaid recipients, the state can make a special exception for recipients because of their health condition. This is called an exemption. An exemption allows recipients not to enroll in an HMO.  See  EXEMPTIONS 

Fee-For-Service Medicaid: When Medicaid recipients are not required to enroll in an HMO, they will be in fee-for-service Medicaid. This allows recipients to go to any doctor or hospital that accepts Medicaid. 

Primary Care Provider (PCP): A PCP is a doctor that you choose from a list that your Medicaid-HMO will give you. The PCP is the doctor who takes care of your day-to-day health care needs and approves visits to hospitals and specialists. The PCP helps the HMO cut costs by restricting unnecessary use of hospitals, emergency rooms and specialists. 

Medicaid-HMO: Health Maintenance Organizations (HMO) are private companies that are contracted by the State of Wisconsin to manage the health care of most Medicaid recipients. 

HMO Advocate: Each HMO has assigned a person to help their enrollees with any questions and concerns that the recipients may have. 

Enrollment Specialist: The Enrollment Specialist provides information to Medicaid recipients about HMOs and managed care. They can help you enroll, choose a primary care provider or request exemptions. They can also answer questions about the different HMO services.  See FINDING HELP 

HealthCheck: This is a special health service for children under age 21 who are enrolled in Medicaid. The law requires that all children receive HealthCheck exams according to a schedule set by law.  See HEALTH CHECK 

Mental Health Gatekeeper: Each HMO contracts with a separate company that you have to contact if you need mental health services or alcohol or drug abuse (AODA) treatment. This provider is known as the gatekeeper.  See  MENTAL HEALTH / AODA SERVICES 

Network HMO: A network HMO is a type of HMO that has doctors in many different locations: not in one building like the clinic-based HMOs. 

Ombuds: This is a program that the state has set up to provide help to Medicaid recipients who are enrolled in an HMO. If you have a problem with your HMO, you can contact the Ombudsman. See OMBUDS PROGRAM 

Out-of-Plan Referral: When your HMO cannot provide the care you need, your primary care provider or HMO can refer you to a doctor outside of the plan. 

Urgent Care Problem: An urgent care problem is a medical problem that isn’t life threatening. An example is a sprained ankle or a minor burn. 

Preventive Care: Health care that helps keep you from getting sick is called preventive care. For example, check ups, mammograms, pap smears, shots, etc.