Which Term Best Describes Those Who Receive Managed Health Care Plan Services

Types of Managed Care Plans

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Managed intendance plans take agreements with certain doctors, hospitals and wellness care providers to provide care to program members at the everyman possible cost. Notwithstanding, not all managed intendance plans are akin.

The following data provides an overview of the major types of managed care plans.

Health Maintenance Arrangement (HMO):

There are many types of HMOs that offer members a range of wellness benefits, including preventive care, for a set monthly fee. You lot must use the health intendance providers and facilities inside the HMO network in order to receive coverage, unless it's an emergency. HMOs will give you a list of doctors from which to choose a master care doctor. The primary intendance doc you lot choose will coordinate your care and refer you lot to a specialist if needed.

Payment: Nearly HMOs require a small copay (a set amount you pay) for each visit to a medico or programme facility. Some require no payment when you visit doctors; however these plans usually have slightly higher monthly premiums. HMOs more often than not provide preventive intendance such every bit well child visits, flu shots, hearing tests, etc., at lower out-of-pocket costs to yous.
Note: If you lot belong to an HMO, the programme only covers the cost of charges for doctors in that HMO. If you get outside the HMO, you pay the nib.

"Full Service" HMO

A "total service" HMO is ane that provides physical and mental health services. However, most people who accept wellness insurance receive their mental health services through a different organization known as a managed behavioral healthcare system (MBHO).

Managed Behavioral Healthcare Organization (MBHO): Many insurance plans contract with MBHOs to provide all of the covered services related to mental health care. This organisation is known as a "cleave out." If your child needs mental health services, you may need to become a special referral from your chief care doctor before seeing the MBHO provider. If your health program uses a MBHO, y'all should exist sure that your child's doctor and mental health provider communicate well-nigh your child's treatment.

Point of Service (POS):

A POS managed care plan is offered an selection within many HMO plans. A POS plan allows members to refer themselves outside the HMO network and still go some coverage.

Payment: If the chief intendance medico makes a referral outside of the network of providers, the plan pays all or most of the pecker. If you refer yourself to a provider outside the network and the service is covered past the programme, yous volition have to pay a per centum of the beak. This is known equally coinsurance.

Preferred Provider Arrangement (PPO):

A PPO is a form of managed care closest to a fee-for-service situation. Doctors, hospitals, and other care providers hold to accept lower fees from the insurer for their services and so that they can exist part of the PPO network. Equally a effect, your toll sharing should be lower than if y'all get "outside the network." Program members can generally refer themselves to other doctors, including ones exterior the plan.

Payment: PPO networks have an established copayment. If you choose to seek care exterior of the PPO network, you will have to run across the deductible and pay coinsurance based on higher charges. Coinsurance is commonly a fixed percentage (e.g., twenty%) of the total cost of the medical service covered based on higher charges. This is in addition to any deductible y'all must meet.

High Deductible Plans (HDP):

HDPs, likewise known as consumer directed health plans (CDHP), are becoming increasing mutual as employers and health plans are shifting more than payment responsibleness to the plan member.

Payment: High deductible plans include large deductibles that the family or patient is financially responsible for. Once the deductible is met, insurance benefits volition kicking in.
Note: The Affordable Intendance Act (ACA) mandates that HDPs purchased after March 2010 provide free preventive services even if the deductible has non been met.
Example: Nether a CDHP with a $1500 deductible, the member would be responsible for the commencement $1500 of covered medical services. Once covered medical expenses reach the deductible amount, insurance benefits will begin.

Last Updated: 11/21/2015

The information independent on this Web site should not be used as a substitute for the medical intendance and communication of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on private facts and circumstances.