1. Managed Health Care
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2. Introduction
Managed Care health insurance offers low cost moderate health care coverage. It’s a system that controls the financing and delivery of health services to members who are enrolled in a specific type of healthcare plan.
The goals of managed health care are to ensure that...
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.

3. Costs Involved Monthly health insurance premium Co-payment
Cost depends on whether you’re
in-network or
out-of-network.

4. Different types of health coverage:
Health Maintenance Organization (HMOs)
Preferred Provider Plans (PPOs)
Medical Savings Plan (MSP)
Point of Service Plans (POSs)

5. HMO’s
A Health Maintenance Organization (HMO) is an organized system of health care that provides comprehensive services to its members for a fixed, pre paid fee.
HMOs are the least expensive form of managed medical care.

6. HMOs place heavy emphasis on controlling costs
A common method to pay network physicians is modified fee-for-service, where payments are based on a negotiated fee schedule
Providers may receive a capitation fee, which is a fixed annual payment for each plan member regardless of the frequency or type of service provided
Some employers have banded together to form purchasing cooperatives to obtain more favourable prices
A gatekeeper physician is a primary care physician who determines whether medical care from a specialist is necessary

7. How HMO’s Work The member picks a provider
A list is set up of the physicians that are covered under the HMO plan and from there the member picks their primary care physician.
The primary care physician must refer a patient out in order to see a specialist.

8. There are four types of HMO’s
Staff Model- physicians are employees of the HMO and are paid a salary and possibly and incentive bonus to hold down costs.
Group Model -physicians are employees of another group that have a contract with an HMO to provide medical services to its members. The HMO pays the group of physicians a monthly or annual capitation fee for each member. In return, the group agrees to provide all covered services to the members during the year. The group model typically has a closed panel of physicians that requires members to select physicians affiliated with the HMO

9. Cont. Types of HMO’s
Network Model -the network contracts with two or more independent group practices to provide medical services to covered members. The HMO pays a fixed monthly fee for each member to the medical group. The medical group then decides how the fees will be distributed among the individual physicians.

10. Advantages of HMO’s
Most services are covered in full with relatively few maximum limits on individual services.
Covered services typically include the full cost of hospital care, laboratory and X-ray services, outpatient services, special-duty nursing, and numerous other services
Office visits to HMO physicians are also covered, either in full or at a nominal charge for each visit.
Some newer HMOs allow insured's to select any physician at higher out-of-pocket costs.

11. Cont. Advantages of HMO’s
HMO members pay a fixed, prepaid fee (usually paid once a month) for the medical services provided.
Because of this fixed pre-paid fee it is in the providers best interest to make sure that the beneficiaries get basic health care for problems before they become serious. This means that beneficiaries get good preventive care through HMO plans.
High deductibles and coinsurance requirements are usually not emphasized.
The big advantage of HMO’s is that there is a huge emphasis on controlling costs.

12. Disadvantages of HMO’s
A big disappointment to many members is that the selection of physicians is usually limited to physicians who are affiliated with the HMO
There is a limit to the amount paid for the treatment of alcoholism and drug addiction and there is now a coinsurance requirement placed for these treatments by HMO’s.
When a beneficiary needs to see a specialist the primary care physician, must refer the beneficiary out

13. Cont. of Disadvantages
HMOs also tend to operate in a specific geographical area and because HMOs operate in a limited geographical area, there may be limited coverage for treatment received outside the area. Usually only emergencies are covered.
In an HMO plan beneficiaries often have to wait longer for an appointment than they would with a fee-for-service plan.

14. PPO Preferred Provider Organization (PPO)
is a plan that contracts with health care providers to provide certain medical services to its members at a discount fee. A health benefit plan with contracts between the sponsor and health care providers to treat plan members.
A PPO can also be a group of health care providers who contract with an insurer to treat policyholders according to a predetermined fee schedule.

15. PPO
PPOs can range from one hospital and its practicing physicians that contract with a large employer to a national network of physicians, hospitals and labs that contract with insurers or employer groups. PPO contracts typically provide discounts from standard fees, incentives for plan enrollees to use the contracting providers, and other managed care cost containment methods.

16. PPO
PPOs can range from one hospital and its practicing physicians that contract with a large employer to a national network of physicians, hospitals and labs that contract with insurers or employer groups.
PPO contracts typically provide discounts from standard fees, incentives for plan enrollees to use the contracting providers, and other managed care cost containment methods.

17. Advantages of PPO
Patients are not required to use a preferred provider but have freedom of choice every time they need care
Costs are lower if you stay within the network of providers
The level of benefits is higher for services from participating providers

18. Advantages of PPO The freedom to seek medical care outside the network
Payment at 100 percent for most covered services once you’ve met your out-of-pocket maximum
No referrals needed or pre authorization for specialists

19. Disadvantages of PPO
Co-payments are higher compared to HMOs however, some employers and consumers are willing to sacrifice the higher level of cost savings of more structured managed-care plans for the increased flexibility.
PPO is generally the most expensive type of managed care plan

20. Disadvantages of PPO
If patients go outside the network, they will have to pay co-payments based on higher charges and they will need to meet the deductible
Members can expect paying co-insurance (co-insurance is usually waived and can be replaced with a low co-payment.)

21. Point of Service, POS Definition
Offers a full range of health services through a combination of HMO and PPO features. Members can elect to receive services under the defined managed care program or can go outside the network for care. If patients see a preferred provider, they pay little or nothing. Outside provider care is covered, but at a substantially higher deductible and co-payments.

22. Introduction to POS
The lesser known health care plan that combines the freedom of a PPO and offers the low cost of an HMO.
When you enroll in a POS you choose your primary care physician to monitor you health.
This physician has to be within the health care network and is considered your “point of service”
Is built into all managed health care plans and allows the individual the option.

23. Advantages of POS
Freedom to choose physicians in network or out of network
Emergency care coverage is covered no matter where you are in the US or worldwide
If you have to relocate temporarily because of a job assignment or a divorce, you will be covered under the Guest Privileges Program
Seeing a physician in network, you do not have to fill out any paper work, co-payments are low & there is no deductible
Annual out-of-pocket costs are limited

24. Costs of POS Costs consists of a monthly premium and a co-payments
Less than a PPO because the health insurance company regulates most of your health care
Example, if you want to see a specialist, you must get a referral from your primary doctor
If your primary care physician chooses, they will probably choose from a specialist that works within the network
These controls reduces the overall cost of a POS health insurance plan

25. Disadvantages of POS Seeing specialists may be difficult
Referrals to see physicians out of network may become difficult
Hospital visits charges by the physicians are considered out of network and charges by the hospital are covered in network.
When seeing physician out of network
Keep track of all information
Fill out all necessary paper work
High costs
Payments of deductibles must be taken care of before coverage can begin
Co-payments are based on usual, customary and reasonable charges