Additional Resources
The most important types of managed care plans are health maintenance organizations 9HMOs) and preferred provider organizations (PPOs). Less common are point-of-service (POS) plans and exclusive provider organizations (EPOs) that combine the features of an HMO and a PPO.
Health Maintenance Organization (HMOs) contract directly with the health care providers. They require that you select a primary care physician (PCP) who is responsible for managing and coordinating all of your health care. PCPs include internal medicine physicians, family physicians and pediatricians to name a few. If you need care from a specialist in the network or a lab test or x-ray, your primary care physician will have to provide you with a referral. These plans have a set copayment for doctor’s visits and prescriptions.
A Preferred Provider Organization (PPO) is a health plan that has contracts with a network of "preferred" providers from which you can choose. You do not need to select a PCP and you do not need referrals to see other providers in the network. For care given within the network, you will be responsible for a copayment for the visit and the annual deductible. Care outside the network will have a higher cost but you have the freedom to choose where you obtain the service.
A point-of-service (POS) plan is a combination of a health maintenance organization and a preferred provider organization. Typically, POS plans have a network that functions like an HMO – you pick a primary care doctor, who manages and coordinates your care within the network. POS plans also allow you to use a provider who is not in the network. However, if you choose to go out-of-network for your care, you will pay more.
Exclusive Provider Organization (EPO) can also be viewed as a hybrid of a PPO and HMO. You can see any doctor in the plan's network, and don't need a referral from a primary care physician (this part is like a PPO). But with the exception of emergencies, there's no coverage for out-of-network care (this part is like an HMO).
Indemnity insurance plan is also known as a reimbursement plan because the insurance reimburses the covered individual regardless of where or with whom the covered individual receives health care services from. With this plan you’ll have freedom to choose your provider and facility. With a fee for service plan, the physician may be paid a fixed amount, known as “usual and customary”.
Managed care plans contract with doctors, hospitals, clinics, and other healthcare providers such as pharmacies, labs, x-ray centers, and medical equipment vendors. This group of contracted health care providers is known as the health plan's "network." In some types of managed care plans, you may be required to receive all your health care services from a network provider. In other managed care plans, you may be able to receive care from providers who are not part of the network, but you will pay a larger share of the cost to receive those services.
Capitation is a payment arrangement for health care service providers such as physicians or nurse practitioners. It pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care. These providers generally are contracted with a type of health maintenance organization known as an independent practice association, which enlists the providers to care for HMO-enrolled patients
Utilization review (UR) nurses work behind the scenes to maximize the quality and cost efficiency of health care services. Through regular reviews and audits, they ensure that patients receive the care they need without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital stays.
Hospital, Insurance Company and HMO Rating
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), evaluates and accredits more than 18,000 hospitals, health care systems, clinics, and health care organizations in the United States. Questions you can ask the hospital on your own:
1. What are the most commonly performed procedures?
2. How many board-certified physicians the hospital has on staff?
Three of the most widely recognized rating firms for insurance companies include:
1. A.M. Best Company which is recognized worldwide as the leading provider of insurance information and company ratings.
2. Moody's examines an insurance company's financial ability to meet its obligations to its policyholders.
3. Standard and Poor's conducts a thorough review of life and health insurers' claim-paying ability.
HMO National Committee for Quality Assurance (NCQA) is a private, non-profit organization dedicated to assessing and reporting on the quality of managed care plans. The NCQA accreditation determines how well a health plan manages its physicians, hospitals, other providers, and administrative services to continuously improve health care for its members.
For More Information
Pacific Business Group on Health This site contains surveys of California Health Plans covering physician care, overall customer satisfaction and much more.
Insurance News Network site includes insurance company ratings from Standard & Poor's.
American Association of Health Plans is the HMOs' largest trade organization's web site. It contains a Resource Center with results of several consumer satisfaction surveys, health plan definitions and more.
Confirming credentials of a Doctor
Here are some questions to consider when selecting a doctor:
-
What medical school did he/she attend?
-
Where did he/she receive specialty training after graduation?
-
Does he/she have another area of expertise?
-
Are they board certified?
-
Have there been any complaints or actions taken against the doctor?
-
Where does he/she have hospital privileges?
-
Is he/she a member of a medical society or association?
To find out this information, you can call:
-
Your doctor himself/herself;
-
Your state or county medical society; or
-
The plan in which the doctor is a participating provider.
For more information visit the American Medical Association (AMA) site which includes links to state and county medical societies, national specialty societies and health-related organizations. You can also refer to the AMA Physician Select to help you choose a physician in your area.