Managed care.In managed care, insurance companies contract with doctors and hospitals to provide health-care services. If managed care health insurance is provided through employment, the employer pays the managed-care plan a set amount of money in advance for all health-care costs. The employer then pays a flat, and usually small, amount for the services--called a copayment co·pay·ment n. A fixed fee that subscribers to a medical plan must pay for their use of specific medical services covered by the plan. copayment, n . In most managed-care plans, doctors or hospitals are chosen from a plan network. Some managed care plans allow for doctors' visits outside the plan, at a greater cost to the employee. The employee must usually get an approval from the plan to see a specialist. [GRAPHIC OMITTED] Types of plans: * HMO HMO health maintenance organization. HMO n. A corporation that is financed by insurance premiums and has member physicians and professional staff who provide curative and preventive medicine within certain financial, (Health maintenance organization); * PPO PPO abbr. preferred provider organization PPO Managed care Preferred provider organization, see there Infectious disease Pleuropneumonia-like organism, see there (Preferred provider organization pre·ferred provider organization n. Abbr. PPO A medical insurance plan in which members receive more coverage if they choose health care providers approved by or affiliated with the plan. ); and * POS (1) See point of sale and packet over SONET. (2) "Parent over shoulder." See digispeak. POS - point of sale (Point of service) Health Maintenance Organization (HMO) WHAT IT IS: The employee in this plan must select a primary-care physician, who oversees all aspects of the employee's medical care and provides referrals to see specialists. Most services received from doctors or a hospital out of the plan's network are not covered not covered Health care adjective Referring to a procedure, test or other health service to which a policy holder or insurance beneficiary is not entitled under the terms of the policy or payment system–eg, Medicare. Cf Covered. . Certain exceptions are made in medical emergencies. WHAT IT INCLUDES: HMO plans usually have copayments--a flat dollar amount--monthly fees and/or deductibles, and have no limits on coverage. Primary-care physicians can include family practice physicians, internists, pediatricians, obstetricians/gynecologists and general practitioners. VALUE TO EMPLOYEES * Reduced costs: Premiums and copayments for office visits, prescription drugs are typically low; sometimes, copayments are flee; and * No paperwork or claim forms needed. VALUE TO EMPLOYERS * Reduced monthly premiums; and * Flexibility in choosing medical and prescription benefits, contribution amounts, and cost-sharing levels. DID YOU KNOW? The term "health maintenance organization" was coined by Dr. Paul Ellwood, a pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children. pe·di·at·ric adj. Of or relating to pediatrics. neurologist from New England New England, name applied to the region comprising six states of the NE United States—Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut. The region is thought to have been so named by Capt. and an adviser to President Nixon, in the early 1970s. His suggestions in part led to The Health Maintenance Organization (HMO) Act of 1973, which was adopted as an answer to a Medicare budget crisis. Preferred Provider Organization (PPO) WHAT IT IS: A network of doctors, hospitals and other health-care providers make up the organization, but the PPO also allows an employee to go to specialists, out-of-network doctors or hospitals without needing prior authorization prior authorization, n See predetermination. prior authorization Health insurance A cost containment measure that provides full payment of health benefits only if the hospitalization or medical treatment has been from a primary-care physician. However, more of the costs to receive care outside the network are shouldered by the employee. WHAT IT INCLUDES: The costs involved in a PPO are specific to the employee's medical needs. Unlike an HMO where members pay a monthly fee for cover age, employees in a PPO pay for medical coverage based on the individual medical services used, and employees may be required to meet a deductible. However, employees in a PPO--like an HMO--are often required to pay a copayment. The amount depends on the type of service received. For example, the rate to visit the doctor likely will not be the same as the prescription-drug rate, or the amount for more complicated treatments. A consequence of having a wider range of coverage possibilities is a greater cost. Since the PPO involves a deductible, out-of-pocket expenses out-of-pocket expenses n. moneys paid directly for necessary items by a contractor, trustee, executor, administrator or any person responsible to cover expenses not detailed by agreement. will likely be higher, and the expenditure amount is set back to zero at the beginning of each year. VALUE TO EMPLOYEES * If employees leave the network for their medical needs, they are still covered to a certain degree; and * No need to have all medical treatment approved by a primary-care physician. VALUE TO EMPLOYERS * Through negotiated, contracted rates, employers can get reduced costs and still offer employees in-network and out-of-network benefits. [GRAPHIC OMITTED] DID YOU KNOW? An EPO EPO see erythropoietin. EPO Erythropoietin, see there , or exclusive provider organization exclusive provider organization (EPO), n a dental benefits plan that provides benefits only if care is rendered by institutional and professional providers with whom the plan contracts (with some exceptions for emergency and out-of-area services). , is similar to an HMO. It restricts coverage of nonemergency care to contracted providers, but rates are negotiated based on services, while HMOs are determined on a per-person basis. Point of Service (POS) Plans WHAT IT IS: These plans combine the features of HMOs and PPOs. The employee must designate a primary care physician, but retains the option of receiving services from doctors without a referral, or go outside the network for care and still get some amount of coverage. WHAT IT INCLUDES: Like an HMO, the employee chooses an in-network physician as a primary-care provider. But like a PPO, patients may go outside of the provider network for health-care services. There is, however, a financial discentive for leaving the network: they will have to pay most of the cost, unless the primary-care provider has made a referral to the out-of-network provider. The medical plan will then pick up the tab. POS plans can be offered by HMOs, PPOs, or self-insured employers. VALUE TO EMPLOYEES * In-network savings with benefits for covered services covered services, n.pl the services for which payment is provided under the terms of the dental benefits contract. Coxiella burnetii a species that causes Q fever in man. outside the network; and * Referrals generally aren't necessary for out-of-network services. VALUE TO EMPLOYERS * Able to take advantage of an HMO's benefits while allowing its employees to self-refer to any health-care provider. [GRAPHIC OMITTED] Indemnity Plans WHAT IT IS: Before managed-care push in the 1980s, indemnity plans were considered traditional. With an indemnity, or fee-for-service plan, there is no network of preapproved providers, so an employee can choose to visit any doctor or hospital he or she wishes. These plans are dwindling dwin·dle v. dwin·dled, dwin·dling, dwin·dles v.intr. To become gradually less until little remains. v.tr. To cause to dwindle. See Synonyms at decrease. , and they cost the most. WHAT IT INCLUDES: The policyholder chooses the health-care provider, meaning that the insurance company could be charged more than the insurance company expected to pay for a particular service. As a result, insurance companies that offer indemnity plans often charge the policyholder a higher annual deductible to protect themselves from the choices the employee may make. Once that deductible has been met, the insurance company pays claims at a set percentage of the "usual, customary and reasonable usual, customary and reasonable (UCR) plan, n a dental benefits plan that determines benefits based on usual, customary, and reasonable fee criteria. See also usual fee, customary fee, and reasonable fee. " (UCR (Under Color Removal) A method for reducing the amount of printing ink used. It substitutes black for gray color (equal amounts of cyan, magenta and yellow). Thus black ink is used instead of the three CMY inks. See GCR and dot gain. ) rate for the service. The UCR rate is determined by the average cost billed by providers in a particular area. Some plans pay 100%, regardless of how much the service cost. The policyholder often must pay the full cost for the service out-of-pocket and then file paperwork themselves to seek reimbursement for the care. If the reimbursement amount is limited, then the policyholder must pay a coinsurance A provision of an insurance policy that provides that the insurance company and the insured will apportion between them any loss covered by the policy according to a fixed percentage of the value for which the property, or the person, is insured. , or a percentage of the total cost. VALUE TO EMPLOYEES * No primary-care providers or referrals; and * Flexibility may appeal to workers who travel often or need to seek care away from home. VALUE TO EMPLOYERS * Employers may get an advantage in attracting and retaining employees by giving them complete flexibility. |
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