Features of Private Payer and Consumer-Driven Health Plans

As far as insurance plans go, generally there are three plans a patient will have, they are Health Maintenance Organization (HM0), Preferred Provider Organization (PPO) and Point-of-Service (POS).

Another type of managed care program that was introduced is the Preferred Provider Organization (PPO). A PPO is comprised of a group of physicians, hospitals and other medical service providers who contract with employers, insurance companies or other plan sponsors. The PPO offers discounted pricing to these contracted organizations due to the high volume of business received. PPO’s typically have up-front cost sharing in the form of deductibles and/or co-insurance, which vary depending upon the actual plan chosen.

Point-of-service (POS) health insurance combines several elements from both HMO and PPO plans. Similar to health maintenance organization plans, (HMO), a member is required to choose a primary care physician and seek referrals to network specialists. Like preferred provider organization insurance, (PPO), members have the choice to receive care from non-network providers but typically incur larger out-of-pocket costs for venturing outside the network.

Unit 2 AssignmentKelley WhitcombKaplan UniversityHI215-01: Reimbursement MethodologiesProfessor Kathleen SobelJuly 20, 2015Medicaid is one of the biggest insurance plans you can get in any state. In the state of Indiana, it is based off of your income. There is a certain amount (income) you have to make to determine if you will receive Medicaid or Healthy Indiana Plan (HIP). HIP is still a form of Medicaid, but you would have to pay monthly cost for it and have certain set of co-pays for certain services that is needed. HIP Plus is the recommended plan for members as it provides health coverage for a low, predictable monthly cost. HIP Plus also covers dental and vision services. If you do not pay your monthly payment you can be removed from

Under the HMO, each patient is appointed to a primary care physician (PCP), who is essentially accountable for the long-term care of the members that she/he has been assigned and any specialists that a patient needs to see should be referred by their PCP. Some examples of HMOs are Kaiser Permanente and Humana. HMOs have been licensed at the state level, under a license that is known as a certificate of authority. A pro of an HMO is that treatment for a patient can begin prior to their insurance being authorized; A member may benefit from this because there would be little to no treatment delays. A con of an HMO is that in order to save cost, most HMOs provide narrow provider networks; A member may not benefit if in an emergency because their “in-network” emergency room might be far or there are “quick-care” in their area.

I currently work for a hospital which is part of an academic medical center. It offers 3 health plan options to choose from. The first is the hospitals own medical plan which which is has features of an EPO, and can be categorized as a CDHP (Consumer Driven Health Plan). It has a higher monthly cost, but lower out-of-pocket costs when care is needed. It has a large network of providers including the hospital, and a network of providers who have partnered with the institution. You are not required to have a PCP, but it is recommended, you must use in-network providers, it has a HIA (Health Incentive Account) with wellness incentive funds available for members. The second is a POS plan from one of the larger Insurance companies with 2 tiers of in-network providers, lowest monthly cost, but a higher out-of-pocket cost when care is needed, until you meet the annual deductible amount. This has a Health Savings Account (HSA) attached, and you can have tax deductible contributions go to the fund, and wellness incentives funds can be deposited into the HSA. The third is an HMO plan with the highest monthly cost, but a lower out-of-pocket cost compared to the POS plan when care is needed. It also has an HIA attached as well.

Insurance is separated into categories called Major Medical Plans, Qualified Health Plans, and Catastrophic Plans. Major medical plans consist of Health Maintenance Organization (HMO) plans: HMOs are one of the most popular types of health insurance you can purchase. With this plan, an entire network of health care providers agrees to offer you its services. You have to select a primary care provider (PCP) who coordinates all of your health services and care (Ehealth, 2014), Preferred Provider Organization (PPO) plans: Under a PPO plan, both you and your family can see any health care provider in their network, including specialists, without a referral. In most cases, you don’t have to

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,

The book discuss about three major types of managed care organization: health maintenance organizations (HMO), preferred provider organizations(PPO), and point of service plans(POS). Managed care has been around for minute. This organization has been around since 1930s. The three managed care organizations are require an agreement between the insurer and a network of health care providers. Policy holders are encouraged to use the providers in the network by the fact a percentage will pay the cost of care if received outside the network.

The same is true of POS plans and indemnity plans. The first plan is a combination of HMO and PPO type plans, by requiring a primary physician whom must approve all coverage, but also allowing you to get coverage outside of your network.

Managed Care is a complex health care system in which physicians, hospitals, and other healthcare professionals organize in an interrelated system of people and facilities that communicate with one another and work together as a unit, commonly referred to as a network. This network coordinates and arranges health care services and benefits for a specific group of individuals, referred as enrollees, for the purpose of managing costs, quality, and access to health care. The Managed care program may be provided in a variety of settings, such as Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). In Health Maintenance Organization, the insurance company will only pay for care within the network. The member will pick a primary care provider who coordinates most of their care. Preferred Provider Organization (PPO) usually pays more if the member will get care within the network, but they still pay a portion if the member will go outside. And Point of Service (POS) plans let you choose between an HMO and a PPO each time you need care (Merrick, 2013).

Today’s options for medical healthcare is a wide stream business that has took off when healthcare became a hot topic on Capitol Hill. Thru the joining of American Association of Health Plans and Health Insurance Association of America a new trade association was created. That medical health insurance is called The America’s Health Insurance Plans (AHIP) it’s currently representing the health insurance industry. Like such a large number of other focused medicinal medical coverage AHIP is one numerous spots that a person will realize that they have an organization that pays special mind to their wellbeing. AHIP has exceptionally solid perspectives on why individual ought to end up becoming a member. They

Health plans cover care for members who have different levels of expected cost and utilization due to differences in demographics and diseases.

The PPO gives discounts, with its doctors and hospitals that participation, and then pays a fee for services given. Patients have a list that they can pick from for a primary physician. The patient pays a set fee per office visit and the insurance provider pays the rest. It’s basically a co-payment which depends on what type of plan they have. However, like an HMO, the PPO has to choose a physician in that network, if they don’t they may be charged a penalty.

The United States being referred for specialties depends on the insurance plan (Mossialos, Wenzel, Osborn, Sarnak, 2016, pp. 171-177). Health Maintenance Organization (HMO) plans give access to certain healthcare organizations and physician within their network that have agreed to lower rates for their services. The individual must agree to these services to have services covered. All services will be coordinated by the primary care physician PCP. Medicaid coverage is also based on these principles. Preferred Provider Organization (PPO) plan have higher premiums but give more flexibility. PPO allows the individual to see any physician they choose but cost is less if the individual stays within the network. PPO does not require that the individual have a PCP. No referrals for specialist are needed.