Aetna HMO, A Primary Care Physician (PCP)

EPO vs HMO-- EPO contracts solely with specific specialists, clinics, hospitals and other health care providers to form a network. EPO clients know they don't have many options when it comes to providers, but they do have the comfort of knowing they'll always be reimbursed for any in-network expenses. HMO’s requires a co-payment on each visit while EPO’s have no co-pays. Both EPO’s and HMO’s keep costs low. EPO’s do not require a referral while HMO’s must confirm that specialized care is required before they will issue a referral

As a single employee with high demands on dental and vision prevention needs, I want to select a PPO medical insurance with dental and vision plans so that I can see my dental doctor and vision doctor under the insurance plan to reduce my cost.

You have open access to indemnity insurance. You have the right to choose your PCP and it doesn’t matter what your insurance may like. This makes things very convenient considering many people go to the same doctor for the vast majority of their life and solely rely on them for their treatment or care.

A Preferred Provider Organization plan is one which permits liberate movement equally within and outside of the organization's contributing provider association. The association may incorporate general physicians, experts, laboratories, diagnostic services, outpatient or free-standing accommodations, hospitals, resilient medical equipment, apothecaries, opticians, holistic/alternative contributors, therapists and more. “Free movement” inside the arrangement is generally referred to as referral-free access (or self-referral) to practitioners, specialists and more. Supplementary arrangement models will necessitate the preference of a Primary Care Physician (PCP) who is subsequently responsible for evaluating your care requirements and composing the applicable referrals for additional maintenance. Though, in a referral-free PPO plan various hospital admissions, diagnostic assessment, out-patient surgical treatment and more will necessitate pre- authorization. This is a procedure of informing the insurance provider of your intents to have specific services provided and basically obtaining their consent to do so. (Conference Associates,

A preferred provider organization (PPO) plan gives patients the flexibility to see providers and specialists within or outside the network of care; it will typically cost less to receive care from an in-network provider (U.S. Centers for Medicare & Medicaid Services, n.d.). In most cases, referrals for specialists and designating one physician as a primary care provider is not required of a PPO plan. (U.S. Centers for Medicare & Medicaid Services, n.d.). Alternatively, a health maintenance organization (HMO) limits patients to receive care from doctors, specialists, and hospitals covered under the health plan (U.S. Centers for Medicare & Medicaid Services, n.d.). With the exception of emergency can and out-of-area urgent care, all care providers

Equally important to the cost is the services of a primary care physician. Providers that are the PCP of the member can determine if specialist are needed. Benefits for specialists are covered under the plan, however members must consult with their PCP for initial service to see if follow-up with specialist or other healthcare provider are needed. Blue Cross Blue Shield of Texas depends on PCP’s for medical records and letters of medical necessity to insure the member is receiving health care benefits that are medically necessary or otherwise. (Blue Cross Blue Shield of Texas,

PEI health plan offers a variety of choices including enhanced access health maintenance organization, enhanced access point of service, a preferred provider organization, or an exclusive provider organization. With each one of these plans that

HMOs have the strictest access structure, called a gatekeeper model, where patients must have a primary care physician (PCP) through whom all care is routed. PCPs decide which diagnostic tests are needed and control access to specialists through referrals, deciding when it is necessary for a patient to seek more expensive specialty care (Barsukiewicz, Raffel, & Raffel, 2010).

There are different types of insurance plans that will meet the different needs of the consumer. The different plan types will provide various levels of coverage for care that consumers can get in and out of the plans network of doctors, hospitals, pharmacies, and other medical service providers. Prudential (my choice to discuss) sold its HMO, preferred-provider organization, indemnity health and dental line to Aetna, making Aetna that largest managed care company (managed care, 1999).

Like all of the administrative rules, the security rule applies to health plans, health care clearing houses, and to any health care provider who transmits health information in electronic form in connection with a transaction for which the Secretary of HHS has adopted standards under HIPAA. Health plans include health, dental, vision, and prescription drug insurers, health maintenance organizations, Medicare, Medicaid and Medicare supplement insurers, and long-term care insurers. Health plans also include employer-sponsored group health plans, government and church-sponsored health plans, and multi-employer health plans. Every health care provider, regardless of size, who electronically transmits health information in connection with certain transactions, is a covered entity. Using electronic technology, such as email, does not mean a health care provider is a covered entity; the transmission must be in connection with a standard transaction. The Privacy Rule covers a health care provider whether it electronically transmits these transactions directly or uses a billing service or other third party to do so on its behalf. Health care providers include all providers of services and providers of medical or health services as defined by Medicare, and any other person or organization that furnishes, bills, or is paid for health care.

Aetna Medicare Plan (PPO) offers advantages such as comprehensive annual examination and fitness facility membership at without a cost, according to Aetna. It also offers in-network coverage regardless of where a member travels to.

The United Healthcare Silver Compass H.S.A. 3600 plan is classified as a HMO plan, in which such plans offer a wide range of health care services through a network of providers that contract exclusively with the HMO, or who agree to provide services to members at a pre-negotiated rate. Since this is an HMO plan I will need to choose a primary care physician who will provide most of my health care services. HMOs are the most popular health insurance plans and this type of plan is best for me because I value preventive care services such as coverage for checkups, immunizations, and similar services, and I prefer to use a primary care provider, rather than

80% of respondents reported that the lack of knowledge about the insurances accepted by the PCP is a major deterrent to why they have never referred to the PCP. 75 % reported the limited rapport with the PCP influences their limited or lack of referral to the PCP program. 85% of employees reported the limited understanding of the services offered by the PCP and their understanding of integration of care influences their decision not to refer to the PCP. 85% of the

Health maintenance organization’s (HMOs) use of the primary care physician (PCP) as the “gatekeeper” initially had MCOs view restrictions as a negative approach to patients’ choices. However, some necessary steps have started to be implemented which reduce unnecessary utilization by enforcing some restrictions.

Ideally, primary care providers are supposed to look out for your best interest and arrange all your health care needs. In reality, you might be unsatisfied with your PCP, and want to