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SolveYourProblem
eLearning Series:
Health Insurance: Your Questions Answered
What does everything mean & how
to choose the right policy
( 18 pages )
HEALTH
INSURANCE PROVIDERS:
HMO Services & PPO's
HMOs are required
to provide the following basic health care services:
- Physicians’
services
- Hospital inpatient
services
- Outpatient
medical services
- Emergency services
- Preventive
services
- Diagnostic
laboratory services
- Diagnostic
and therapeutic radiology services
Many HMOs may
also provide the following, but are not required to do so:
- Prescription
drugs
- Vision care
- Dental care
- Home health
care
- Nursing services
- Long-term care
- Mental health
care
- Substance abuse
services
Those who would
like supplemental services may purchase them from the HMO
only as an addition to the basic health care services that
the HMO provides.
Co-payments. HMO
members may be charged only nominal amounts for basic services
in additional to the original monthly payments. In some cases
there may be no additional payments for services. All details
are spelled out in a descriptive document which is known
as either the certificate of coverage or evidence of coverage.
Gatekeeper. HMOs
most often have this type of system wherein a primary care
physician must be selected who in turn will authorize all
care for a member including referrals to specialists.
Twenty four hour
access. Normally members have 24 hour access to the HMO.
Open Enrollment. This
term can apply in one of two different ways. An employee
sponsored group has a set time period each year when employees
may choose to enroll or remain enrolled or change plans.
The second meaning is a period each year when an HMO must
advertise to the general public on an individual basis.
Nondiscrimination. When
HMO services are offered to a group, the HMO may not refuse
to cover an individual member of the group due to pre-existing
health conditions. This practice is much different from traditional
insurers where adverse conditions may preclude enrollment.
Complaints. HMOs
must be set up to handle coverage complaints and care complaints.
HMO members must receive a document that spells out how complaints
can be registered.
Prohibitive
practices. In addition to non-discrimination against
group members based on their health status during enrollment,
HMOs are not allowed to cancel or dis-enroll members because
of their current health status or the amount of usage of
health services. HMOs are also not allowed to use words
that may imply that the HMO provides insurance in the traditional
manner.
Preferred
Provider Organizations (PPO)
Preferred Provider
Organizations are another attempt to reduce medical costs.
This is an arrangement whereby a selected group of independent
hospitals and medical practitioners in a certain area agree
to provide certain services at a prearranged rate.
The organizers
and providers agree upon medical service charges that are
generally less than the provider would charge patients not
associated with the PPO.
These differ from
HMOs in that the providers are paid on a fee for service
basis rather than receiving a flat monthly amount and the
organizer or contracting agency might be:
- Traditional
insurance companies
- Blue Cross/Blue
Shield
- Local groups
of hospitals
- Local groups
of physicians
- An existing
HMO
- Large employers
- Trade unions
Those people who
will receive services select a preferred provider from a
list that the PPO distributes. Usually the choices are more
extensive with a PPO than a HMO.
Sometimes PPOs
and HMOs are lumped together and called a managed care system.
One characteristic still exists concerning regulation, however.
HMOs increasingly have to meet state requirements as well
as standard established by federal government. PPOs are less
stringently regulated since any group that can agree on the
arrangements can call itself a PPO.
 
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