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Managed Care Plans
The term "managed care"
insurance has become a common healthcare term which refers
to healthcare plans that are designed to provide medical care
at the lowest cost possible. The way managed care plans provide
affordable coverage is by requiring patients to follow certain
guidelines. The three major types of managed care insurance
plans are:
- Preferred
Provider Organizations (PPOs)
- Health
Maintenance Organizations (HMO's)
- Point-of-Service
(POS) plans.
Preferred Provider Organizations (PPOs)
PPO plans are similiar
to Fee-for-Service plans. The difference is that a PPO has
contracts with a network of physicians, hospitals and other
medical providers who have agreed to receive lower fees from
the insurer for their services. As a result, your cost sharing
is usually lower than if you go outside the network. PPO plan
members have the benefit of going to doctors outside the plan
but usually at a higher cost. This is one of the advantages
of the PPO plan compared to the HMO, that members enjoy the
lower costs in the plan network but still can receive medical
services outside the plan if desired or necessary.
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Most PPO plan members pay a copay (ex: $15 for doctor
visit and $10 for prescriptions) if
you go to a doctor within the PPO's network. Your coinsurance
cost are
lower within the plan's network.
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The
coinsurance costs are higher as well as possible deductible
requirements for plan members who go outside the network
for medical services. You also might be required to
pay any differences between the out-of-network medical
bills and what the PPO plan is willing to pay.
(Each health insurance plan has its own policy,
so read carefully.)
Health Maintenance Organizations
(HMOs)
HMO
plans provide many healthcare benefits and services for a
fixed monthly premium. Like PPOs, HMOs also have a network
of doctors and hospitals for plan members for the purpose
of providing low cost health coverage. The disadvantage compared
to PPO, is that members can only receive medical services
within the network (except in emergencies) in order to receive
coverage. Most HMO's require a small copay (ex: $5 for doctor,
$10 for prescriptions) or no copayment when visiting a doctor
or plan facility. Another benefit of HMOs is that they usually
provide "preventive" healthcare for very low cost
such as annual physicals, flu shots, vaccinations, cholesterol
tests, etc.. Many people like HMO plans for this benefit!
Types
of HMO's:
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The Staff Model HMO's
- the physicans and nurses at the plans medical facility
are employees of the HMO company.
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Individual Practice Associations
(IPAs) - type of HMO which contracts with outside
doctor networks or individual physicans and plan members
visit them in their own offices and medical facilities.
Primary
Care Physicians:
HMO's usally provide their members with a list of doctors
from which the member chooses a "primary care physican".
The member would then be required to visit their pimary doctor
first before getting any needed referrals to a specialist.
Primary care physicians fall into one of the
following specialties:
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Family practice doctors
or general practitioners - Doctors
that specialize in a variety of health problems. It is
the most common choice for a "primary care physician".
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Internists
- Doctors who specialize in internal medicine such as
diabetes and heart disease. So, for example, members with
high blood pressure might prefer to choose an Internist
as their doctor.
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Pediatricians
- Doctors who treat only children, usually under 12 years
of age.
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OB/GYN - Some
plans allow women of childbearing age to choose an OB/GYN
doctor as their primary care physician.
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Other types of doctors
- Specialists can sometimes be chosen as a primary care
physican for members with certain medical conditions.
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How do you choose a primary care
physician?
HMO's usually only provide a list of their
doctors' names. You can find out more about the Physicians
by ...
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Asking for recommendations from other
plan members.
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Making appointments to meet with the
doctors to see which one you prefer.
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Asking for recommendations from the
staff nurse, if the plan's physicans are located in the
same facility
Can you use your current
doctor?
Unless your current doctor belongs
to the HMO, you'll have to find another doctor who is in the
plan network. Most HMO plans allow you to change primary care
physicians many times per year if you're not satisfied with
your current doctor.
Fee-for-Service and Managed Care Similiarities
While Fee-for-Service and managed care plans
are different, they can be similiar in some ways. Many managed
care plans contain Fee-for-Service characteristics. Likewise,
most Fee-for-Service plans incorporate managed care techniques
for desirable patient care and lower costs. Therefore, it
is wise to carefully read the policies of your plans of choice.
You might find certain Fee-for-Service benefits in a low cost
HMO plan or on the other hand, you may find that a particular
Fee-for-Service plan has too many restrictions for the price.
Plan Guidelines
Every Fee-for-Service, PPO and HMO plan has
certain guidelines that members must follow.
Emergency medical care is usually included in
your plan coverage. Any emergency services at a hospital outside
your HMO's network are normally covered. However, if the doctors
at the hospital believe that you need certain non-emergency
treatment, then the hospital needs to get "pre-authoriziation"
from your HMO to approve the medical service.
Utilization review
Utilization review is the process by insurers
to determine if a certain medical service is necessary. If
for example, you read about a particular medical procedure
for a health condition or ailment from which you suffer, and
your doctor thinks that it would be a good procedure but not
absolutely necessary, then a Medical Review Specialist would
be called upon to determine whether your insurer will cover
the cost or not.
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