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Health maintenance organizations Essay

There are nine private payer plans which include preferred provider organizations (PPO), health maintenance organizations (HMO), point of service (POS). Indemnity plans cost the most for employees and they usually have to choose a PPO plan. The new consumer driven health plan (CDHP) which a lot of people are picking, it has a high deductible combined with a funding option of some type. All of the plans have unique features for coverage of services and financial responsibility. PPO plans are the most popular plan that doctors, clinics, hospitals, and pharmacies contract with.

One of the reasons that the PPO plans are so popular is because they pay the doctors a discounted fee for service based on their fee schedule. PPO plans offer a low premium that has a higher deductible or the other option is a high premium with a lower deductible. The patients are responsible to pay a copayment, and there is also a yearly deductible that the patient has to pay out of pocket. If a patient sees a doctor outside of the network without a referral, the plan will pay less and the patient is responsible for the remainder of the fee.

Patients have their choice of providers, but if the patient goes to a out-of-network provider it will cost more. One thing to remember though is that all non-emergency services require pre-authorization. With HMO plans there is a list of providers that the patient can only go to, if they go to a doctor that is not in the list of providers they will have to pay extra. The only way that a patient should see a provider out of the network is if it is an emergency. HMO’s have an annual premium and a copayment that is due at the time of service.

The main services the HMO’s cover is preventive and wellness checks and disease management. However, in order for complete coverage the enrollees must see a doctor that offers an HMO plan. The providers manage the care and referrals are required, low payments, ad this plan does cover preventative care. The indemnity plan allows the patient to see any physician but there are preauthorization’s required for some of the procedures. Their features are higher costs, there are deductibles, coinsurance payments, and preventative care is not usually covered.

Consumer Driven Health Plans (CDHP) has two elements that are included in this plan. One being a health plan, which is normally a PPO. This plan has a higher deductible and lower premium. Second is the special savings account which is used to pay medical bills before deductible is met. Point of service (POS) is similar to an HMO plan; specifically called an open HMO. This plan reduces restrictions, allowing members to choose providers outside of the HMO. However, a penalty fee is charged.


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