Health Insurance Show
Traditional health insurance allows you to select your health care providers, such as your favorite doctor or hospital. You may have to pay for services when rendered and then submit the bill to the insurance company for reimbursement of the portion it agreed to pay under the policy. Often, the provider submits the bill directly to the insurer for you. Managed Care, which combines the delivery and financing of health care services, has gained acceptance over the years. It may restrict your choice of doctors and hospitals, but in return you typically pay less for medical care compared to traditional coverage. The managed care network will control and direct access to your health care services. Types of Managed CareHealth Maintenance Organizations (HMOs) HMO members pay a monthly amount (similar to a monthly insurance premium), which gives them access to a wide range of health care services. In most cases, members remit a copayment for each doctor or hospital visit and for each prescription drug, rather than paying the provider in full and obtaining a portion of the reimbursement later. Recent regulatory changes have provided HMOs with the opportunity to offer plans with deductibles and coinsurance similar to PPOs (see below). HMO members often have little or no paperwork to complete due to the elimination of reimbursement. Members are required to use the HMO's network of providers, and typically visits to specialists are covered only with a referral provided by the member's primary care physician. Under HMO plans, emergency care (for life-threatening conditions) typically is covered without any requirement that the member utilize network providers. Exclusive Provider Organizations (EPOs) In the EPO arrangement, an insurance company contracts with hospitals or specific providers. Insured members must use the contracted hospitals or providers to receive benefits from these plans. Some EPO plans, however, have been designed to include "out-of-network" benefit schedules (more cost-sharing for the insured) that apply to any non-contracted provider practicing within the designated local area. Outside of the local area, only emergency care will be covered by the EPO plan. Preferred Provider Organizations (PPOs) A PPO offers another kind of provider network to meet the health care needs of consumers. A traditional insurance carrier provides the health benefits. An insurer contracts with a group of health care providers to control the cost of providing benefits to consumers. These providers charge lower-than-usual fees because they require prompt payment and serve a greater number of patients. Consumers usually choose who will provider their health services, but pay less in coinsurance with a preferred provider as compared to using a non-preferred provider. With most PPOs, insureds can self-refer to specialists for care without first having to visit their primary physician to get a referral. Point-of-Service Plans (POS Plans) These plans are called by a variety of names and have varying features. They combine some aspects of traditional medical insurance plans and other aspects of HMOs and PPOs. In a POS plan, insured members may choose, at the point of service, whether to receive care from a physician within the plan's network or to go out of network for services. The POS plan provides less coverage for health care services provided outside the network than for services incurred within the network. Also, the POS plan usually requires higher coinsurance costs for medical care received out of network. Back to Top | Back to Health Insurance Home
Free Downloads:Serving all of Tampa Bay Click here to request a Personalized Insurance Quote! AH Insurance Services, Inc. By calling one of these numbers or mailing to the above addresses, I understand I will be directed to a licensed insurance sales agent or broker. Y0070_NA030737_WCM_WEB_ENG_02 CMS Approved 02/16/2016 WellCare (HMO) is a Medicare Advantage organization with a Medicare contract. Enrollment in WellCare (HMO) depends on contract renewal. Last Updated: 08/31/2022 What is a provider organization in healthcare?A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan's network.
What is an organization that contracts with a network of providers for the delivery of healthcare for a prepaid premium?HEALTH MAINTENANCE ORGANIZATION (HMO): A company that provides, offers or arranges for coverage of health services needed by plan members for a fixed, prepaid premium.
Which of the following types of organizations are prepaid group health plans where members pay in advance?1. Health Maintenance Organization (HMO) HMOs offer prepaid, compre- hensive health coverage for both hospital and physician services. An HMO contracts with health care providers, e.g., physicians, hospitals, and other health professionals. Members are required to choose a primary care physician (PCP).
What is a network model HMO?Network model HMO—An HMO that contracts with multiple physician groups to provide services to HMO members. It may include single or multispecialty groups. Staff model HMO—A closed-panel HMO (where patients can receive services only through a limited number of providers) in which physicians are HMO employees.
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A medical care provider which typically delivers health services at its own local medical
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