Managed care is a bundled health care service which ensures better health benefits at effective cost. Insurance organizations offer these services through a network of medical services which are either part of their company or contracted with private medical associations to work together. Different health insurance plans target managed care under three different plans. These are health maintenance organization (HMO), preferred provider organization (PPO) and point of service (POS). One can choose from them according to their medical needs and financial status. The top health insurances in US include Aetna, Kaiser Foundation, HCSC, United Health, Wellpoint Inc., Highmark, Coventry, and Cigna. The three managed care plans are discussed below:
Health Maintenance Organization (HMO)
Under a health maintenance organization (HMO), the insured is provided comprehensive health care under a monthly prepaid plan. Parts of HMO services are:
- The insured might have to cover small expenses such as visit fee to doctor.
- Little paperwork is involved. The insured carries a medical card to claim the services.
- There are almost no or limited options to choose practitioners outside the HMO network.
- As part of the package, preventive care benefits include regular checkups, immunizations, tests.
- The insured is appointed a primary care physician who can only refer to specialists.
How HMO works:
HMO works with a medical services network including doctors, therapy, lab facilities, emergency care, hospital stays. The fees are already negotiated to provide the cheapest insurance to the insurer.
Preferred Provider Organization (PPO)
With preferred provider organization, the insured gets the freedom to take preferred medical services from a doctor outside of network while still receiving an appreciable insurance coverage.
- This plan works well for the insurers who travel a lot, have a member or two in family requiring special care, due to work environment or changing lifestyle and other reasons.
- Preventive care benefits are part of the overall PPO insurance plan.
- If the insured seeks doctors out of PPO network, a copayment and an annual deductible will be charged from him/her. If the annual deductible is met, the insured will be required to pay coinsurance of 30%, the rest will be covered by PPO.
- An amount of paperwork is involved when you choose a medical facility outside of the PPO network to claim insurance.
- The insured can have wide control in health care plan.
Point-of-Service Plan (POS)
A point-of-service plan provides many flexible medical benefits of choice of doctors from the network and outside it. The premium plans get reduced with high deductibles. The insured has complete health care benefits.
- A primary care physician refers the insured to the specialists in network and also to the doctors outside of network.
- A copayment and coinsurance forms part of most medical services.
- The insured is required to submit claim papers to get insurance benefits.
- The insured can suggest a doctor from outside, in which case high coinsurance is paid by him/her.
- Deductibles are applicable on individual and family plans.