For many years people felt that they were trapped between a traditional indemnity health insurance plan (a wide range of choice and high degree of security in the event of serious accident or illness which came at a high cost) and a managed care plan (a focus on preventative medicine at relatively low cost but with severely limited choice).
Today however it is possible to some extent to enjoy the benefits of both traditional indemnity insurance and managed health care through a variation on the original Health Maintenance Organization (HMO) model known as a Preferred Provider Organization (PPO).
A PPO is essentially an HMO which means that the insurance company will establish a network of healthcare providers and, in exchange for a relatively low cost, will encourage, or in some cases require, policyholders to seek treatment within the HMO’s network. Where treatment is taken outside of the HMO’s network much, if not all, of the cost of such treatment normally has to be borne by the policyholder. However, in the case of a PPO, the rules for policyholders who wish to seek care outside of the HMO’s network are relaxed.
Within an HMO a policyholder is assigned to a particular doctor or primary care physician (often referred to as a “gatekeeper”) and the policyholder must go through the primary care physician in order to receive treatment. If, for example, the policyholder wishes to see a specialist then he or she will have to be referred by the primary care physician and may or may not have a say in which particular specialist they are referred to.
In a PPO however no primary care physician is assigned and so no referral is required. Policyholders are free therefore should they choose to do so to seek treatment through a specialist who is not a member of the HMO’s network.
There are of course cost implications to this choice and policyholders will almost certainly have to pay more for treatment with a doctor or in a facility that is outside of the HMO’s network than they would if they sought treatment within the network. Nevertheless, unlike the HMO model, the PPO gives the policyholder the choice.
If you like, a PPO provides policyholders with the low cost managed health benefits of the HMO with the option to elect for the greater choice, albeit higher cost, of indemnity insurance when it suits their needs.
It will probably come as no surprise to find that today traditional indemnity policies are fast disappearing and that there are now twice as many people enrolled in PPOs as there are in HMOs.
By: Donald Saunders
Posts Tagged ‘Policyholders’
A Traditional Indemnity Health Insurance Plan Or A Managed Care Plan?
March 20th, 2010Health Insurance Covering Families in Michigan
February 4th, 2010
UNICARE health insurance provides individuals and families low rate coverage and comprehensive plans. Few of the UNICARE policies have low cost plans, with “$2,000” yearly deductibles for each family member, thus offering the maximum payout on claims. The plan may offer waivers on deductibles to family members that do not meet the limited doctor visits. In other words, the policy may stipulate that each family member is permitted two doctor visits in 12 months, and if the policyholder does not meet the limits then deductibles may be waived. The plans offer a “$30” Co-payment per member.
Be careful, since some plans charge 100 percent on three or more visits to the doctor. The plan may have low pricing with maximum deductibles of “$5000,” however, the doctor limits are increased. This means the higher the deductible the more visits you can spare, with waiver on deductibles and “$30” Co-payments. There may also be co-payments on prescription drugs, usually around $10 per prescription on generic brands.
It depends on the insurer but few offer low cost plans with higher deductibles and “tax deferred” bargains. The insurance provider may pay 100 percent of each visit to the doctor, which will include procedures, visits, hospital stay, outpatient care, and so forth. If the policyholder meets the deductibles then the company may pay the full price on prescription drugs generic brands.
If you are fall under the low-income guidelines, you may want to inquire about HMO PLANS. Rather, you may want to inquire about other types of HMO plans, since the UNICARE falls under the guidelines of low-income families.
HMO is an abbreviation of Health Maintenance Organization, and the plan is designed to meet the delivery of healthcare. The plan is constructed under a network, meaning that doctors, policyholders, and providers work together to provide coverage at lower cost to families and individuals. It is a managed health care plan that works within a network environment. This means that if you have an HMO plan then you are expected to get healthcare by the participants in the plan. In other words, the doctors have voluntarily agreed to charge less for medical care and have agreed to join the plan. If the doctor is not in the network then you may not be permitted to go out of the networking environment. If you need a specialist then you must ask your doctor for a referral, otherwise you cannot visit a specialist on your own without paying full price out of your own pocket. HMO is a Medicare program that is under rule of the “Federal Government,” following the “Medicare Advantage Program” rule.
At one time policyholders of HMO plans were permitted to go anywhere they choose to get medical treatment under the plan; however, the networking environment has increased restrictions and included exclusions under the plan. If you are in need of specialist care you may want to consider other types of managed care or insurance polices that do not have exclusions or works on a network environment.
If you apply for HMO and are accepted, you will also need to sign up for the “Medicare Part D” to receive coverage for prescriptions. There are two types of plans available, which include the HMO and PPO policies. Thus, if you do not apply for the “New Prescription Drug Benefit” you will need to cover your own medicine costs. Still, you will only get the generic brand with the HMO coverage plans. Furthermore, it depends on the plans, but few HMO plans with prescriptions have no premiums, while others may charge minimal premiums per policy. There are also deductibles in few of the HMO plans, including the D plan.
For more information regarding health insurance, it makes sense to go online and find all information as possible regarding premiums, rates, coverage and so forth. Online you can get several quotes to help you determine cost of health care services. Many insurance policies will include co-payments; however, Michigan is one of the states that offer HMO plans that do not have co-payments. Recently, Michigan HMO plans restored Chiropractic and Dental services to its plan; however, at one time there was no coverage for these services.
By: Michael Bens
Low Cost Individual Health Insurance
January 4th, 2010
Health insurance is any arrangement that helps to delay, defer, reduce or altogether avoid payment for health care incurred by individuals and households.
If you do not have group insurance, or if the insurance offered is very limited, you can buy an individual policy. There are number of low-cost individual health insurance policies like fee-for-service, HMO, or PPO protection.
In fee-for-services health insurance you have a pre-agreed health insurance sum, and when you make a claim your health insurance provider deducts this from your pre-agreed health insurance sum. The cost of a fee-for-service health insurance is high, but the benefit of fee-for-services health insurance is that you can visit any healthcare provider you want, but at the same time you need to remember that there are some types of treatment are not covered.
Health Maintenance Organizations (HMOs) are a recently introduced but popular insurance coverage. The main reason for its popularity is its very low cost in premiums. But HMOs do not give you the flexibility to visit any health care provider. They designate certain healthcare providers who you are allowed to visit and if, even in the case of an emergency, you visit a healthcare provider who is not approved by the HMO, you’ll be left to pick up the entire tab yourself.
PPOs, or preferred provider organizations, serve only a specific group or association, and are a good option because they have lower fees with a network of health care providers. They give their policyholders a financial incentive to stay within that network and, as a PPO member, you pay for services as they are received and are reimbursed for the cost of the treatment less your co-payment.
By: Kristy Annely
