A majority of companies decide to offer their employees health insurance through health insurers. Health insurers offer options referred to as managed care plans. These managed care plans offer a variety of services such as physician office visits, emergency care, prescription drug coverage and more. Payments are based on whether the member uses a service that’s covered by the network and what type of managed care plan they have. There are three basic types. The most basic and inexpensive of health insurance plans, an HMO, or health maintenance organization, gives its members basic healthcare coverage. A business may choose to offer an HMO due to its affordability.
The members of this plan must choose a Primary Care Physician in network who is the primary care giver of all their needs. Although the primary care provider is the main doctor for your common sickness, if they feel like you need a specialist, a referral is needed. Once a member is referred they do have to make sure that the specialist is an in network doctor, or else they end up paying the bill. A POS, or point of service plan, is slightly more inclusive than an HMO plan. Some companies that offer HMO will offer a POS if they know many employees see physicians outside of the health plan’s network. With a POS plan, health plan members still have to see a PCP to coordinate their care and are dependent upon them for referrals.
Unlike an HMO, health plan members can seek care outside of the plan’s network. If a member chooses to see a provider outside of the network, the individual will pay more than the in-network co-pay. The benefit is still positive due to that person still paying less than if they had seen that provider while on the HMO plan. The most comprehensive plan, a PPO, or preferred provider organization, gives members the freedom that HMO and POS plans limit. Since they are so comprehensive, they can also be cost prohibitive to smaller businesses. PPO members do not necessarily have to choose a PCP. Members can seek services both in and outside of the health plan network, though like the POS plan, higher payments apply to out-of-network services. Yet unlike the POS plan, members can see a physician or specialist without a referral.
Kaiser Health News
Within the last few decades, healthcare in the United States has been gradually skyrocketing out of control. In today’s healthcare market place, the financing of health care has greatly contributed to the increase in health care costs. According to Kaiser Health news, “Currently, the United States spends more on health care services than any other country, exceeding $2.6 trillion, or about 18 percent of gross domestic product. (2014)” Numerous factors should as chronic conditions, new medical advances and technologies, lifestyle choices, and chronic obesity help to fuel rising costs. Managed care is a type of insurance that contracts with medical providers, hospitals, clinics, and specialty care groups to provide medical care for members at a reduced or discounted rate. There are three types of managed care plans, which are health maintenance organizations, preferred provider organizations, and point of service plans.
Managed Care plans work off the basic premise that health care costs can be better controlled by controlling access to health treatments and services. While this may be true and beneficial to the companies offering these plans, from a patient’s perspective, it can be difficult to get approval for health care that goes beyond basic preventative care. This goes to say if a member of a managed care plan needs to go to a pain management specialist, but there are none in network in the area, or the one who does participate is not excepting new patients at the time. Also another issue with pain management is sometimes although the primary care provider is referring the member, the specialist may have the member do a series of paper work to determine whether or not they are eligible.
Another advantage of managed care is that many health insurance plans include a wide range of in network doctors, specialist, and pharmacies they participate with. In some cases this can be excellent for the member because really all they need to do is call in to their health plan for assistance. If for some reason they cannot locate one who is participating for the member, than one will be found for them who is participating. For people who may be somewhat intimidated by having to find and qualify specialists for needed medical procedures, the fact that the managed care plan includes a roster of physicians who have already been qualified by the insurance provider can be extremely helpful. Also you should have access to these providers, just as the insurance company does. Whether it is via web, pamphlet, or phone, there should be access to this information when needed (“Wisegeek”, 2003-2014.)