Question

in your own words describe the difference between PPOs, POSs and HMOs.

Answer 1

the difference between PPOs, POSs and HMOs:-

All PPOs , POSs and HMOs are types of managed health care insurance plans . Every insurance plan give different services, these services can be acquired through a network. Every health insurance plan have different network and service provider differ in there services. Knowledge of PPOs , POSs and HMOs is very important to get your medical claim paid or abandon confusion regarding your plan.

Managed health care plan :- Managed health care plans are health insurance plans which gives a health insurance policy to individual members of an organization. The employer of organization is sponsor of managed care plan. By getting more bias rates of health insurance plan or cost effective medical insurance services from health provider network the beneficiary get facilitated by managed health care insurance plan.

PPO PPO is termed as Preferred Provider Organization: PPOs have a network of providers they prefer that we use, but they’ll still pay for out-of-network care.PPO have higher monthly premium’s and sometimes require higher cost sharing. PPos are less restrictive as compared to other health insurance plans . PPO become less popular than HMOs and POSs plans because they have reduced the size of their providers network and it cost more than other plans.

EPO = EPO is termed as Exclusive Provider Organization: EPOs have a network of providers they use exclusively. One must hold to network providers on that list or the EPO won’t pay medical claims. However, an EPO generally won't allow a referral from a primary care physician in order to visit a specialist. EPO are more likely similar to PPO but without coverage for out-of-network care.

HMO HMO is termed as Health Maintenance Organization: HMOs have a lower monthly premiums and lower cost-sharing than plans with very few network restrictions, but they require primary care provider (PCP) referrals and won’t pay for care out-of-network except in emergencies.

There are six basic ways HMOs, PPOs, EPOs and plans differ from each other:-

(1.) requirement of primary care physician (PCP)

(2.) requirements to have a referral to see a specialist or get other services

(3.) Requirement to have health care services pre-authorization.

(4.) Does health plan will pay for the care you get outside of its provider network

(5.) cost-sharing you’re responsible for paying when you use your health insurance

(6.) Requirement of filling insurance claims and documentation.

(1.) HMOs require pcp ( primary care physician). Primary care physician coordinates services individual need like physical therapy or home oxygen. He also organize the care you receive from specialists. EPO and PPO plans do not require a PCP.

(2.) health plans which require primary care physician also require to have a referral from your PCP before you see a specialist or get any other type of non-emergency health care service. Requiring a referral is the health insurance company’s way of keeping costs in check by making sure you really need to see that specialist or get that expensive service or test.There is drawback of this plan that sometimes PCP does not agree on whether you need a treatment or not thus there is a delay in visiting specialist. HMOs require referral however PPO and EPOs does not require referrals.

(3.) Pre authorization:- Health plans keep costs in check by making sure you really need the services you’re getting. In HMO plans individual require to have a PCP, that physician is primarily responsible for making sure you really need the services you're getting. Plans that don't require a PCP (such as EPO and PPO plans) use pre-authorization as a mechanism to check whether you need treatment or not. the health plan only pays for care that's medically necessary. If individual don’t get pre authorization insurance plan refuse to pay the claims or cost of treatment.

(4.) Out of network care:- If you see a specialist out of network or get a test out of network some health plan would not pay the cost of medical treatment. All health insurance plans differ as individuals have coverage for health care services from out of network care providers.

(5.) Cost-Sharing:- Cost-sharing means paying for a portion of your own health care expenses. In brief it means individual will have to share the cost of health care expenses with health insurance company. Deductibles, copayments, and coinsurance are all types of cost-sharing.

(6.) Filing Claims:- If individual get services from out-of-network, individual is generally responsible for filing the claim paperwork with chosen health insurance company. If individual stay in-network than the doctor, hospital, lab, or other provider will file any necessary claims.in health insurance plans which do not cover out of network provider individual don't need to file the claim because insurance company will not pay the claims.