Managed Care Plans Essay

PPO- This plan contracts with physicians and facilities to perform services and a specified rate. Its to ensure that PPO members are charged less than nonmembers

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

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.

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

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 three managed care organizations all share a similar idea of health. Health organization and point of service plans both allows patients to choose PCP as gatekeeper to coordinate care; while preferred provider

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 (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

Instead, customers are encouraged to use providers within the network through offering them reduced rates for service. When a customer uses a provider that participates with the program, they pay less in the form of out of pocket copayments. These discounts are available because the health care providers within the network have contracts with the PPO stating the agreed upon discounted rates the providers will be paid when they provide services for members of that particular PPO (Gapenski, 2013).

HMO (Health maintenance organizations), POS (point-of-service), and PPO (preferred provider Organization) are all different varieties of plans that all the various health insurance companies offer. Each plan offers different services. An HMO would be the least expensive and therefore have the least amount of benefits and care has to be done by network providers that are in the network unless it is an emergency and you are required to get referrals to see specialists. An PPO has a larger network than an HMO; and people can go to out of service providers and receive some benefits and there is no requirement for referrals to see specialists. A POS is a combination of HMO and PPO; you can go out of network but you need a referral if you don’t want

The preferred provider organization (PPO) falls between conventional insurance and HMO’s. There is not network of physicians to choose from, you can see the doctor you prefer. PPO’s are more expensive than HMO’s.

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.

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).