Question

QUESTION 1 What are the differences among HMO's, PPO's and IPA's?

Answer 1

1 ) ans)

HMO:

A Health Maintenance Organization, or HMO, is a network of healthcare providers who agree to provide services at lower prices negotiated by an insurance company.

Members choose a single physician from a list of approved healthcare providers. HMO members HMO can only see a health care specialist such as an obstetrician, rheumatologist, cardiologist, etc. if they get a referral from their(PCP), who is also known as the gatekeeper.

Various services/benefits provided by an HMO can differ depending on the company and the health plan. It may cover health screenings, cancer screening, prescribed medications, laboratory tests, X-rays, and other scans. HMOs usually cover prenatal care and well-baby care.

PPO:

A Preferred Provider Organization or PPO is also a network of healthcare providers who provide its members with multiple choices regarding healthcare and healthcare providers.

PPOs do not restrict patients to receiving care in-network. It’s optional to designate a PCP (primary care physician). Patients can make appointments directly with the providers and referrals aren’t required.

Usually, PPO plans provide better benefits and lower costs for services availed from network providers, which covered persons are encouraged to use. However, members can also receive care from providers outside of the network, although they will likely pay more for it.

Major difference of HMO AND PPO:

Provider networks:

A network is a group of healthcare providers that are under contract with insurance companies to offer discounted services for a particular HMO or PPO plan. They typically include general physicians, along with specialists such as dermatologists and chiropractors. In order to receive coverage in an HMO, you must first see your PCP, no matter what the problem is. If they can’t treat you, they will refer you to someone else within the network. Staying within your network in an HMO plan, you can expect maximum insurance coverage. Go outside of the network and your coverage vanishes. With a PPO, you can visit doctors outside the network and still get some coverage, but not as much as you would if you remained in the network.

Cost analysis:

With a PPO, the trade-off for receiving the freedom of choice and flexibility is higher premium costs for the plan. An HMO offers no coverage outside the network but patients enjoy lower premium costs.

Claims forms:

With an HMO, patients do not need to file a claim because healthcare providers are paid directly by the insurance company. Under PPO, however, patients must sometimes first pay out-of-network providers and then file a claim for reimbursement from the insurance company.

Services covers:

The range of services provided under the two plans depends on the company and the type of plan taken, but are usually similar.

Prescription:

Just like the coverage under a HMO is limited to a network, so are the pharmacy locations where one can get their prescriptions filled and covered under the plan. PPOs allow patients to fill a prescription almost anywhere but with additional charges for an out-of-network pharmacy.

Exception:

Patients with an HMO plan do not need a referral during an emergency or for in-network visits to a gynecologist or obstetrician.

IPA's:

An Individual Practice Association provides both insurance coverage and medical services . Physicians practicing in their own offices participate in the prepaid health care plan, charge patients agreed upon rates, and bill the IPA on a fee-for-services basis.