Question

Managed care focuses on reducing costs and managing benefits through participating provider networks. Create a 1-2 page Word document that describes three (3) types of managed care models (i.e., HMO, PPO, etc.). Include an example of an insurance plan for each model. (i.e., Blue Cross Blue Shield, Cigna, United Healthcare, etc.). Discuss the effects of managed care on physician practices for each model. Discuss the impact of cost reductions and other factors for each of the models. Be sure to include your references in APA format on a References slide at the end of the presentation

Answer 1

Health Maintenance Organization (HMO)

An HMO delivers all health services through a network of healthcare providers and facilities. With an HMO, you may have:

• The least freedom to choose your health care providers
• The least amount of paperwork compared to other plans
• A primary care doctor to manage your care and refer you to specialists when you need one so the care is covered by the health plan; most HMOs will require a referral before you can see a specialist.

Premium: This is the cost you pay each month for insurance.

Deductible: Your plan may require you to pay the amount of a deductible before it covers care except for preventive care.

Copays and/or co-insurance for each type of care. A copay is a flat fee, such as $15, that you pay when you get care. Coinsurance is when you pay a percentage of the charges for care, for example, 20%. These charges vary according to your plan and they are counted toward your deductible.

Any in your HMO's network. If you see a doctor who is not in the network, you'll have to pay the full bill yourself. Emergency services at an out-of-network hospital must be covered at in-network rates, but non-participating can doctors who treat you in the hospital can bill you.

Preferred Provider Organization (PPO)

With a PPO, you may have:

• A moderate amount of freedom to choose your health care providers more than an HMO; you do not have to get a referral from a primary care doctor to see a specialist.
• Higher out-of-pocket costs if you see out-of-network doctors vs. in-network providers
• More paperwork than with other plans if you see out-of-network providers

Premium: This is the cost you pay each month for insurance.

Deductible: Some PPOs may have a deductible. You will likely have to pay a higher deductible if you see an out-of-network doctor.

Copay or coinsurance: A copay is a flat fee, such as $15, that you pay when you get care. Coinsurance is when you pay a percentage of the charges for care, for example, 20%.

Other costs: If your out-of-network doctor charges more than others in the area do, you may have to pay the balance after your insurance pays its share.

Any in the PPO's network; you can see out-of-network doctors, but you'll pay more.

Exclusive Provider Organization (EPO)

With an EPO, you may have:

• A moderate amount of freedom to choose your health care providers -- more than an HMO; you do not have to get a referral from a primary care doctor to see a specialist.
• No coverage for out-of-network providers; if you see a provider that is not in your plan’s network – other than in an emergency – you will have to pay the full cost yourself.
• Lower premium than a PPO offered by the same insurer

Premium: This is the cost you pay each month for insurance.

Deductible: Some EPOs may have a deductible.

Copay or coinsurance: A copay is a flat fee, such as $15, that you pay when you get care. Coinsurance is when you pay a per cent of the charges for care, for example, 20%.

Other costs: If you see an out-of-network provider you will have to pay the full bill.

Any in the EPO's network; there is no coverage for out-of-network providers.

Point-of-Service Plan (POS)

A POS plan blends features of an HMO with a PPO. With the POS plan, you may have:

• More freedom to choose your health care providers than you would in an HMO
• A moderate amount of paperwork if you see out-of-network providers
• A primary care doctor who coordinates your care and who refers you to specialists

Premium: This is the cost you pay each month for insurance.

Deductible: Your plan may require you to pay the amount of a deductible before it covers care beyond preventive services. You may pay a higher deductible if you see an out-of-network provider.

Copays or coinsurance: You will pay either a copay, such as $15, when you get care or coinsurance, which is a per cent of the charges for care. Copayments and coinsurance are higher when you use an out-of-network doctor.

You can see in-network providers your primary care doctor refers you to. You can see out-of-network doctors, but you'll pay more.