Managed Care Plans Essay

HMO- Is the most popular of the plans and is a group of providers that provides services to subscribers with a very small or even co copay when services are rendered. There actually are various types of HMO's that link providers to create a healthcare delivery system, they are Group Model HMO, Individual Practice Association HMO, Network Model HMO, Staff Model HMO, and Open Access HMO.

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.

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.

An HMO provides comprehensive health-care services to the insured for a fixed periodic payment. There may also be a nominal fee paid for each visit to a health-care provider. Unlike traditional insurance, HMOs actually provide the health care rather than just making payments to health-care providers. HMOs can have a variety of relationships with hospitals and physicians. Plan physicians may be salaried employees, members of an independent multi-specialty group, of a network of independent multi-specialty groups, or part of an individual practice association.

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.

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

Benefits offered and covered services under this EPO managed health plan provides for the payment of benefits only when the members utilize providers in the Blue Choice Network (EPO, n.d.). Contracted providers including physicians, specialty care providers, hospitals are those that provide the health care services at negotiated contracted rates and the only ones the members and use for healthcare. Most providers can be

The relationship of an HMO and its physician member is to help provide a wider range health care for its patients and a wide area of services available for its physician members. A patient must choose a primary care physician from a list of providers. The relationship with the physician provided from the HMO is in a contract that is to deliver services to their patients for a fee. There can also be a group plan which is a HMOs contract with a group of physicians to deliver services. The HMO organization compared to PPOs, a PPO is a variation of an HMO, and it features traditional insurance and managed care.

Preferred provider organizations offer flexibility in benefit design and allow patients flexibility to choose from a list of in-network providers for their care. Care provided in-network typically is discounted with out of network services resulting in higher out of pocket expenses to the patient (Hirth, Grazier, Chernew and Okeke, 2007). Clinically integrated networks are a more recently developed managed care structure. In this model, independent practitioners form a virtual network as a means of increasing capacity for contracting with payers of healthcare whether commercial insurance or for self-insured organizations. Physicians recognize advantages to collaborative contracting and the increase in coordinating care of patients through the network (Kaplan and Guest, 2012). Commercial insurance companies are looking to clinically integrated networks as another mechanism to control the costs of healthcare delivery. Accountable care organizations, as with clinically integrated networks, are fairly recent phenomenon with similar but more formalized characteristics. An accountable care organization is a structured network of healthcare entities which have united and are responsible for the health of an identified population. The accountable care organization shares the risk of meeting the health needs of

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

The types of managed care are differentiated by definition, operation, structure, and information needs. `HMOs were the most common type of MCO until commercial insurance companies developed PPOs to compete with HMOs' (Douglas, 2003, p.331). `HMOs are business entities that either arrange for or provide health services to an enrolled population after prepayment of a fixed sum of money, called a premium' (Peden, 1998, p.78). There are three characteristics that an HMO must have. The first is a health care financing and delivery system that provides services for members in a particular geographic area. Second, is ensured access to a complete range of health care services, health maintenance, treatment, and routine checkups. Last, health care must be obtained from voluntary personnel that participate in the HMO. The five HMO models related to the participating physicians are the Staff

Point-of-service (POS) plans involve both HMO and PPO networks. Members have the choice of either a primary or a secondary network. Primary networks are like HMOs, and secondary networks are like PPOs. In a POS plan, annual premiums and copayments are required from the members. Although monthly premiums are higher, visits to non-network providers in the specialty fields are an added benefit to the member with some coverage being provided by the POS plan. Structured as a tiered plan, the POS might pay different rates for specially designated providers, regular participating providers, and out-of-network providers according to the plans guidelines (Valerius, et al 2008).

A health maintenance organization (HMO) plan provide health care for the member using a network of hospital and physicians. Comprehensive benefits include preventive care, well baby care and immunizations. This plan is less expensive, due to the fact that the employee must stay within the network, giving him a limited choice in the choice of physicians and treatment.

Individuals enrolling for this plan need to select a chief physician from the health care network. In case individuals choose to opt for a doctor outside the network, then they have to pay a higher price with a limited compensation from the company.