Medical Insurance Plans
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How would I compare two insurance companies that offer managed care plans - Health Maintenance Organization (H.M.O.), and Preferred Provider Organization (P.P.O.),
a. What are the similarities in what they offer?
b. What are the differences in what they offer?
c. What are the member/patient incentives?
d. What are the innovations promoted?
e. What are the facilities and patient satisfaction practices?
f. does either have provider incentives and what are they
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The expert examines medical insurance plans for future classes.
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Managed Care: Health Maintenance Organizations and Preferred Provider Organizations
Introduction
Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) form the most common types of managed care health insurance plans. Overall, members receive services from a network of approved providers; physicians or hospitals- that contracts with the sponsor. To this end, managed care plan administrators (Insurance company/brokers) contract with health care providers and enrollees to deliver medical services. Subscribers benefit from reduced health care costs, and the health care providers profit from the premiums paid and the guaranteed client base (INC, 2012). HMOS and PPOs are both "managed care organizations", and so they both mange the health care services of individuals. That said, however, there are similarities, and differences.
HMOs
HMOs are your basic health care plan. They are usually contracted with various groups of physicians based on their specialties. Likewise, members/enrollees receive service based on their specialized needs. Under the Doctors are then and in essence; employed by the managed care plan sponsor. As such, one could say the HMO "owns" the facility and pays salaries to the doctors they have contracted and negotiations with. If member need services from a physician specialist in the network or a lab test; or x-ray, their primary care physician (PCP) will have to provide them with a referral. If they do not have a referral or members choose to obtain services from a provider who is outside of the HMO's contracted network; that member will most likely have to pay all or most of the costs. This is usually referred to as "out of pocket expenses." (OOPE)(INC, 2012).
For small businesses in the market for a health care plan, HMOs are cost-effective, fairly broad coverage, and not too much administrative work. Although members /employees are more limited in terms of choosing their own doctors and they are limited for out-of-network (OON) coverage with HMOs; members do have the advantage of low out-of-pocket (OOP) costs; comprehensive services; preventative care, and there are ...
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