Unit 17: Other Health Plans Flashcards
What are health maintenance organizations (HMOs)?
•managed care entities
•provide both the health care service & the health care financing
•made up of an array of physicians, hospitals, & other medical providers who offer a full range of health care services
•individuals pay for services directly to the HMO & it agrees to provide needed medical care
•finance entities & assume that the cost of medical care will not exceed the subscription fees
•considered prepaid plans
•in addition to a co-pay paid by the subscriber, the HMO pays a capitation fee to a health care provider
—>the capitation fee is a fixed monthly fee paid to the healthcare provider based on the number of HMO members, NOT per HMO subscriber visit or service
What is a co-pay?
A relatively small, flat dollar amount that subscribers must pay for each doctor visit
What is the gatekeeper concept (primary care physician)?
•another way HMOs control overutilization of their services by subscribers
•when subscribers join an HMO, they must choose a doctor with a general medical practice as their primary care physician (PCP) & they must always see them first (except in emergencies) when seeking medical care from the HMO
•subscribers cannot see specialists without a referral from a primary care physician
Limited choice of provider
•HMO subscribers must choose a provider/physician under contract with the HMO
•if a new subscriber’s physician is not under contract with the HMO, they must choose a doctor from the HMO
•in some cases, the individual’s current doctor may be able to join the HMO
Limited service area
•HMOs operate within a specific geographic area or “designated service area” such as a certain county or within the surrounding area
•individuals must live within the designated service area to subscribe to the HMO
What are the features of HMOs?
•managed care
•prepaid services
•co-pays
•gatekeeper (primary care physician)
•limited choice of providers
•limited service area
Preventive care
•HMOs seek to reduce the need for medical treatment by detecting conditions early before they require more extensive treatments
•routine physicals, well-child care, immunizations, & diagnostic screening are all included in the HMO subscription fee
Emergency care
•HMOs must provide emergency care, including ambulance service, available 24 hours a day & 365 days a year, within its designated service area
•HMOs must reimburse subscribers for emergency care obtained outside of the HMO’s designated service are from non-HMO providers
What is included in hospital services?
•inpatient hospital & physician care must be provided for a period per calendar year for treatment of illness or injury
Include:
•room & board
•maternity care
•general nursing care
•use of operating room & facilities
•use of ICU
•x-rays, laboratory, & other diagnostic tests
•drugs, medications, & anesthesia
•physical, radiation, & inhalation therapy
Other services
•HMOs must also provide for other basic office-based care provided by physicians & other medical professionals such as diagnostic services, treatment services, short-term physical therapy & rehabilitation services, laboratory & x-ray services, & outpatient surgery
•may include certain supplemental health care services or provide them for an additional fee, such as:
-prescription drugs
-vision care
-dental care
-home health care
-nursing services
-long-term care
-substance abuse treatment
What are preferred provider organizations (PPOs)?
•managed care entity
•fee for service
•pre-negotiated rates
•insured pays less in network of PPO providers
•a risk-bearing entity separate from the providers of health care services
•the relationship between the PPO & it’s providers is contractual
•contract with a network of hospitals, physicians, laboratories, & other medical practitioners to provide medical services for a few that is somewhat lower than the usual rate for that area
•individuals sign up to receive their medical care through the PPO in order to take advantage of the lower fees
•providers agree to accept a lower fee in order to have access to the PPO’s subscribers
•operate on a fee-for-service basis
•subscribers pay an insurance premium when they enroll in the PPO
—>premium is generally less than an HMO fee
—>BUT, they have deductibles, coinsurance, & co-pays
•out of pocket costs depend on the amount of care provided
Closed-panel/closed network
•typically HMOs are these
•subscribers must seek care only from providers/physicians that belong to the HMO (except in out-of-network emergencies)
Open panel/open network
•PPOs are these
•entities & subscribers are not strictly limited to the plan’s providers
—>HOWEVER, reimbursement % on care received from out-of-network providers is usually considerably lower
What organizations can a PPO be organized by?
•insurance companies
•blue cross/blue shield
•a hospital or a group of hospitals
•a group of physicians
•an HMO
•a large employer or group of employers
•a trade union
What are point-of-service (POS) plans?
•HMO allows subscribers to use providers outside of the HMO
•no gate keeper for out of network services
•subscribers pay more of the cost
•called open-ended HMO
•type of HMO
•allows subscribers to obtain care from providers who do not belong to the HMO as well as those who do
•subscribers can choose their point of service
•if subscribers choose to access care within the HMO, they choose a primary care physician who acts as gatekeeper to the HMO’s network as providers
—> sometimes referred to as “gatekeeper PPOs”
•in-network care is covered by the subscriber’s prepaid fee
—>no billing is done & no claim forms need to be completed
If subscribers choose to access care outside of the HMO, the plan operates like a PPO or traditional insurance plan:
•no primary care physician
•providers bill the individual a fee for services renders & the individual must submit a claim done to the HMO for reimbursement
•subscribers are only reimbursed for a % such as 60% or 80% of their expenses like a coinsurance requirement
•sometimes called “open-ended HMOs” because subscribers are not limited to selected only providers which belong to the HMO
