Health Insurance Structure

Managed health care is a system used to control costs, quality of and access to health care services, as well as the delivery of health care services to it’s members. Managed health care started in the 1980’s in response to rising health care costs and new, advancing technology and equipment, which costs more to operate. Members can enroll in one of these three types of health care plans.

What is managed care? According to the Oxford English Dictionary, managed care is “a system of health care in which patients agree to visit only certain doctors and hospitals, and in which the cost of treatment is monitored by a managing company.” Managed care is a variety of techniques designed to essentially reduce the cost of providing health benefits and advance the quality of care. In the United States alone, there are various managed care programs, that span from less restrictive to more restrictive. As recently stated in the National Institutes of Health, the future of managed care is uncertain. It is enthralling to note that in spite of the advances in the health care systems, such as our hospital’s ability to provide patients

The same is true of POS plans and indemnity plans. The first plan is a combination of HMO and PPO type plans, by requiring a primary physician whom must approve all coverage, but also allowing you to get coverage outside of your network.

Managed Care is a complex health care system in which physicians, hospitals, and other healthcare professionals organize in an interrelated system of people and facilities that communicate with one another and work together as a unit, commonly referred to as a network. This network coordinates and arranges health care services and benefits for a specific group of individuals, referred as enrollees, for the purpose of managing costs, quality, and access to health care. The Managed care program may be provided in a variety of settings, such as Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). In Health Maintenance Organization, the insurance company will only pay for care within the network. The member will pick a primary care provider who coordinates most of their care. Preferred Provider Organization (PPO) usually pays more if the member will get care within the network, but they still pay a portion if the member will go outside. And Point of Service (POS) plans let you choose between an HMO and a PPO each time you need care (Merrick, 2013).

There are different types of insurance plans that will meet the different needs of the consumer. The different plan types will provide various levels of coverage for care that consumers can get in and out of the plans network of doctors, hospitals, pharmacies, and other medical service providers. Prudential (my choice to discuss) sold its HMO, preferred-provider organization, indemnity health and dental line to Aetna, making Aetna that largest managed care company (managed care, 1999).

People monthly premium can be a lot lower based on people income. No matter which health insurance plan people choose. They can save a lot money on their monthly insurance based on their income. The difference between HMO Health Maintenance Organization and PPO Preferred Provider Organization. These two health plans help people compare plans to get the right coverage for them and their family. A HMO health plan is a type of plan where people can pick one primary care Physician acts as the gateway between you, family, and your care. It also plans often offer the best pricing and least flexibility. They have lower prices by limiting your care to the doctors, clinics and hospital within the HMO a network. It require to choose primary care physician

Health Maintenance Organization (HMO) is medical insurance group that provides health services for a set annual fee. The primary reason of managed care is to reduce health care costs among Americans. The belief behind managed care programs was to maintain good health that will be accomplish by preventing diseases and providing quality care. By having good health the cost in health care can be controlled and lowered. Managed health care organizations became contracted with groups of health care providers such as HMOs and PPOs. HMOs covers care provided by physicians and other professionals who have agreed by contract to treat patients in following with the HMOs guidelines and rules in exchange for patients. PPOs are known as preferred provider organizations where individuals can only receive care from providers in contract with PPO. Payment arrangements between managed health care organizations and care providers are made in advance.

Health insurance has been a matter of concern for long in the U.S. Several laws have been formulated to ensure every individual get insurance cover. The latest law is the Affordable Care Act. Every insurance company has its own products offered. There are various types of insurance offered. The most common types of health insurance plans are health maintenance organization (HMO), Exclusive Provider Organization (EPO), Preferred Provider Organization and Point of Service (POS) Plans.

medical and surgical expenses. The “provider” is a clinic, hospital, doctor, laboratory, health care practitioner, or pharmacy. The “insured” is the owner of the health insurance policy; the person with the health insurance coverage.

There are many types of healthcare plans in the United States. Two types of care are Managed Care Organizations (MCO) and Accountable Care Organizations (ACO). Today the drawback of MCOs are, the features of consumer-driven healthcare plan (CDHP), the difference between HMO and PPO plans verses CDHP, and the features of ACOs that control cost and improve quality of care.

Managed care is the provision of health care services being taken on by a single organization in the management of finances, insurance, delivery and payment (Shi, Singh, 2017). Additionally, managed care plans are a type of health insurance that contracts with health care providers and medical organizations, whereas the members are provided care at a reduced cost, usually the lowest possible cost. The amount paid depends on the rules of a specific network.

I think the best managed care plan for patients is a PPO plan. This type of plan provides the most flexibility for patients, especially those who need critical care such as surgery or cancer treatments etc.

Under the plans listed above, the managed care plans (HMO, PPO, and POS) offer the best methods of containing costs while encouraging accountability and patient outcomes. Each plan has limitations because of the structure of the program. For example, HMOs can manage costs and encourage accountability, but may restrict patient outcomes because of the organizational acceptable care plans to treat certain diseases. HMOs manage care by utilizing general care which may or may not treat the specific disease that the patient is suffering from and limits the types of acceptable pharmacological treatment for the disease. This can be frustrating for both the provider and the patient because of the limitations placed by the

The insurance system is an important topic for all providers, employees and individuals of this country to understand. Insurance allows patients to be seen by healthcare providers without having to pay large medical bills. It is the ability for physicians to treat patients and then able to get reimbursed. Health insurance is a privilege in our country because not only does it save families time from stressing about money, but also it allows each individual the ability to receive good quality care. In fact, there are two forms of health insurance, social and private. Social health insurance is a government-owned program that benefits the citizens of our country. There are three types of social insurance, Medicare that covers elderly people, Medicaid that covers poor people and

Let’s take PPO’s and HMO’s plans and compare the difference. The word “preferred” means that the plan is designed to have contracts with doctors and medical facilities that perform services for their members at a lower rate than the non-members and a referral does not need to be obtained in order for the patient to see a specialist (Pearson 2015). This means that a consumer will not have to compromise between searching for the best physician and searching for what is affordable. Then we have the HMO plan which is the most affordable plan and has a lot more benefits to offer than the PPO plan, but it does come with restrictions for those patients with serious health conditions. HMO’s offer very limited and strict network of physicians and other healthcare professionals with limitations on what is covered by the plan and many patients have to pay out-of-pocket expenses if services are not within the network. Overall, this plan is lower than the PPO plan but it has many drawbacks. Before choosing a healthcare plan, be sure to