HMO Vs. PPO Plan

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.

EPO’s vs PPO’s—PPO’s are more flexible when it comes to physician choices than EPO’s. EPO’s are less expensive than PPO’s. Neither plan require a primary care physician. EPO’s do not cover out-of-network where PPO’s do pay for out-of-coverage services. PPO’s have higher premiums and have a deductible.

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.

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.

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.

Today, there are several types of managed care plans including Preferred Provider Organizations (PPOs), HMOs, and Point-of-Service (POS) plans. There are many types of HMOs that offer members a variety of health benefits. An HMO plan requires the member to use health care providers and facilities within the HMO network in order receive coverage, unless it is an emergency (Andrews, 2014, p. 1). A PPO is a form of managed care that most resembles a fee-for-service type situation. The plan members can generally refer themselves to doctors, including doctors outside the plan, although they typically will pay a higher percentage of the cost if the doctor is out of the network (Andrews, 2014, p. 1). A POS plan allows members to refer themselves outside the HMO network and still get some coverage (Andrews, 2014, p. 1). While these

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

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).

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

People monthly premium can be a lot lower based on people income. No matter which health insurance plan people choose. They can save a lot money on their monthly insurance based on their income. The difference between HMO Health Maintenance Organization and PPO Preferred Provider Organization. These two health plans help people compare plans to get the right coverage for them and their family. A HMO health plan is a type of plan where people can pick one primary care Physician acts as the gateway between you, family, and your care. It also plans often offer the best pricing and least flexibility. They have lower prices by limiting your care to the doctors, clinics and hospital within the HMO a network. It require to choose primary care physician

An HMO is an organization whereby the subscriber, or patient, is allowed to choose a medical provider from a list of doctors within a certain medical group. Each physician

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.