Managed care healthcare is a system that controls the financing and delivery of health services to members who are enrolled in a specific type of healthcare plan. Managed care healthcare plans are out to provide its members with the following benefits:
- providers deliver high-quality care in an environment that manages or controls costs.
- the care delivered is medically necessary and appropriate for the patient’s condition.
- care is rendered by the most appropriate provider.
- care is rendered in the most appropriate, least-restrictive setting.
The three major types of managed care healthcare plans are Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), and Point-of-Service Plans (POS).
The characteristics of an HMO include the following:
- An HMO has contracts with physicians, hospitals, and other healthcare professionals to form a provider network.
- Members of an HMO can only obtain care from providers that are contracted by the HMO network if the patient wishes to have his or her care reimbursed.
- The members of an HMO network have to select a physician that will be their primary care physician. The primary care physician will provide the patient with general healthcare services.
- The member of an HMO can only see a specialist, such as an allergist, with a referral from the primary care physician. If there is no referral present the HMO will not pay for the services rendered.
The characteristics of a PPO include the following:
- A PPO signs a contract with healthcare providers such as hospitals doctors, nurses, and other healthcare professionals to form a provider network.
- The member of the PPO does not need to select a primary care physician but is encouraged to use a physician from the PPO network. If they do so they might receive lower deductibles or co-payments.
- Members of a PPO do not need a referral to see a specialist but might receive certain financial rewards if they use network specialists.
- A PPO plan typically requires a higher out of pocket payment from members than an HMO plan.
The characteristics of a POS plan includes the following:
- A POS plan is an open ended plan because its members will have to choose whether they want to use an HMO or PPO each time they seek care.
- A POS has a preselected network of healthcare professionals.
- Members of a POS plan are encouraged to seek their own primary care physician but are not required to do so.
- Members of a POS plan can see doctors out of their network if they so wish to do so.
- POS plans offer more options and freedoms to members of the network than an HMO plan does.
When determining which plan is best for you consult the help desk of your local insurance company for answers to questions regarding each plan available for purchase. Each plan will cover patients when it comes to illness or injury but in different ways. Never sign up for a healthcare plan without knowing all of the benefits and prices for the benefits.
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