Hsm 546 W1 Dq2 Managedcare Plans

Front 1

HSM 546 W1 DQ2 ManagedCare Plans

Back 1

Download answer at https://www.examtutorials.com/course/hsm-546-w1-dq2-managedcare-plans/
<b>Week 1: Managed Health Care Structure - Discussion</b> <b>Managed-Care Plans (graded)</b><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td>What are PPO and POS plans? How do HMO plans differ from PPO plans?</td></tr></tbody></table> <b>Responses</b>Responses are listed below in the following order: response, author and the date and time the response is posted.<table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="11"></td><td width="11"></td><td><b>Response </b></td><td width="160"><b>Author </b></td><td width="116"><b>Date/Time </b></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/2/2013 8:29:24 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td><p align="center">There are several principal significant control elements in a PPO and an HMO. This week we will address not only the types of managed care plans but we will look at the various staff models of each. We cannot just state that a plan is an HMO but we have to look at the type of model structure the plan uses. Who would like to lead us off this week?<b>What are PPO and POS plans? How do HMO plans differ from PPO plans?</b></p> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Guertty Lopez</td><td width="185">3/3/2013 12:10:48 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td><b>Modified:</b>3/4/2013 5:50 PM</td></tr><tr><td width="93"></td><td><i>"The POS plan combines an HMO health plan with indemnity (or service plan) coverage for care received outside of the HMO. The plan has the following characteristics: </i><ul> <li><i>Primary care physicians may be reimbursed through capitation payments (ie, a fixed payment per member per month) or other performance-based reimbursement methods.</i></li> <li><i>There may be an amount withheld from physician compensation that is paid contingent upon achievement of utilization or cost targets. Some states restrict the ability of managed care organizations to establish withholds, and they have become less common over time.</i></li> <li><i>The primary care physician acts as a gatekeeper for referral and institutional medical services.</i></li> <li><i>The member retains some coverage for services rendered that either are not authorized by the primary care physician or are delivered by nonparticipating providers. Such coverage is typically significantly lower than coverage for authorized services delivered by participating providers is (eg, 100% compared to 60%). </i></li></ul><i>PPO's are entities through which employer health benefit plans and health insurance carriers contract to purchase health care services for covered beneficiaries from a selected network of participating providers. The participating providers agree or abide by the utilization management and other procedures implemented by the PPO and agree to accept the PPO's reimbursement structure and payment levels. In contrast with the HMO coverage, individuals with PPO coverage are permitted to use non-PPO providers, although a higher co-payment or higher deductible could be required. The key common characteristics of PPOs include the following:</i><ul> <li><b><i>Provider network.</i></b><i> PPOs typically establish a network by contracting with selected providers in a community to provide health services for covered individuals. Most PPOs contract directly with hospitals, physicians, and other diagnostic facilities. Providers can be selected to participate on the basis of their cost efficiency, community reputation, and scope of services. Some PPOs assemble massive databases of information about potential providers, including costs by diagnostic category, before they make their contracting decisions. As a practical matter, however, PPOs now rarely deliberately limit the size of their network but rather contract with any provider willing to accept the terms and conditions of the PPO contract.</i></li> <li><b><i>Negotiated payment rates.</i></b><i> Most PPO participation agreements require participating providers to accept the PPO’s payments as payment in full for covered services (except for applicable copays, coinsurance, or deductibles). Although negotiating payment rates with physicians and other professional providers may take place, it is more common for the PPO simply to inform the physician of what payment rates will be, which the physician can either agree to and contract with the PPO, or not agree to in which case they do not become a PPO provider. PPOs attempt to negotiate payment rates with hospitals that provide them with a competitive cost advantage relative to charge-based payment systems. These payment rates usually take the form of discounts from charges, fixed fee schedules, all-inclusive per diem rates, or payments based on diagnosis-related groups. Some PPOs have established bundled pricing arrangements for certain services, including normal delivery, open-heart surgery, and some types of oncology.</i></li> <li><b><i>Utilization management.</i></b><i> Many PPOs implement utilization management programs to control the utilization and cost of health services provided to their covered beneficiaries. In the more sophisticated PPOs, these utilization management programs resemble the programs operated by HMOs.</i></li> <li><b><i>Consumer choice.</i></b><i> Unlike traditional HMOs, PPOs generally allow covered beneficiaries to use non-PPO providers instead of PPO providers when they need health services. Higher levels of beneficiary cost sharing, often in the form of higher copayments, typically are imposed when PPO beneficiaries use non-PPO providers."</i></li></ul> (Kongstvedt, p. 25-27)In contrasting both plans, POS and PPO are very similar in that they both offer services outside of an HMO network, but with PPO there is more flexibility and going to out-of-network providers may also cost more than with a POS. Under both health plans, the member is not required to have a primary care physician. Also, unlike PPO where a deductible is usually required, the POS has low co-payments and no deducitble. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Letitia Armour</td><td width="185">3/3/2013 6:50:13 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Professor Johnson-Warren and Class,PPO is a group of doctors and hospitals that provides medical service for only a specific groups. The PPO is set u through a particular insurance company, by employers, and by an organization. PPO pays for services as it rendered to them. PPO's does require one to choose the primary care physician in the network.POs plan is a type of manged healthcare system that combines the same way HMO sysem works. POS pays no deductible and you have to request a referral from your primary physicians and work out of the network of specific physicians available.HMO plan differ from PPO plans because HMO must choose a primary care physician and PPO does not. PPO does not need to get an referral to see a specific doctor. Also, HMO could have problems if the primary physicians cannot provide a specific doctor that is not on the network. The patient may need a specific physician and because they are not able to provide it, it could cause difficulty for the patient.<a href="http://www.agencyinfo.net/iv/medical/types/hmo-ppo-pos.htm">http://www.agencyinfo.net/iv/medical/types/hmo-ppo-pos.htm</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Laura Wimberly</td><td width="185">3/3/2013 9:18:24 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>HMO (Health Maintenance Organization) plans differ from PPO (Preferred Provider Organization) plans where patients choosing which doctors to see, the cost of services and how medical records are kept. Major difference is the option of selecting a health care provider. Within the HMO programs patients are required to select a primary care provider which will refer them to medical specialist unlike the PPO plans which allows patients to select any health care provider within network or not.Source: Wisegeek.comL. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/5/2013 10:09:33 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Thank you Laura for your post.The PPO usually has a modest price advantage because of its lower fee schedule, but this may not be significant. A nonselective PPO may not achieve any real savings; however, a selective PPO with aggressive UM may be able to control its costs better than the typical service plan. Because the PPO does not employ the use of a “gatekeeper,” it is perceived as offering a wider choice of providers. In addition, the PPO generally has modest benefits differentials for going out of network.What is a Nonselective PPO vs a Selective PPO? </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Julie Gildemeister</td><td width="185">3/6/2013 8:18:15 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>I hope someone will correct me if I'm wrong . . .As I understand it, a selective PPO will choose or recruit providers based on a predetermined set of criteria, which may include productivity and quality of care. A nonselective PPO will welcome any provider who agrees to abide by the terms of the PPO contract. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="235"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/6/2013 10:14:24 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="258"></td><td>Thanks Julie for your definition,Your definition is sound and effective. A nonselective PPO may not achieve any real savings; however, a selective PPO with aggressive UM may be able to control its costs better than the typical service plan. Because the PPO does not employ the use of a “gatekeeper,” it is perceived as offering a wider choice of providers. In addition, the PPO generally has modest benefits differentials for going out of network. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="290"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Stephanie Lynch</td><td width="185">3/7/2013 6:19:16 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="313"></td><td>Don't they also go back and add/change criteria to be selected year after year? The physicians need to continue meeting those criteria to remain in the PPO. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="345"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/7/2013 11:12:04 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="368"></td><td>Thanks Stephanie. Good question.It depends on the contract. Just like any other insurance there's room for changes based on the martket on case-by case basis. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Letitia Armour</td><td width="185">3/7/2013 8:32:14 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>Professor Johnson-Warren and Class,Nonselective PPO allows the patient or customer to choose the specific specialist or doctor of their choice and allow them to pay a % of what the total bill would be. Selective PPO do not have a choice to decide on a which doctor ir will be chosen by the group policy referrals. The patient will be billed the balance of whatever the insurance does not pay. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Jodie Knox</td><td width="185">3/5/2013 7:21:18 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>My basic understanding of Preferred Provider Organization (PPO) and Point-of-Service (POS) plans is that they offer more options and freedom of choice for the patient than a traditional Health-Maintenance Organization (HMO) plan. Both PPO and POS are types of HMO plans but they allow users to go to out-of-network providers. With POS, generally, members have to have a primary doctor and PPO this is not a requirement. With both plans, though they allow the patient to choose out of network providers, the patient usually has to pay more.Jodie </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Sheriker Bellard</td><td width="185">3/5/2013 12:29:09 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>The difference between a HMO and a PPO is an HMO is has a primary care provider that you must see before seeing a specialist. A PPO is a preferred provider organization that gives the patient an option to see other doctors that are in network, which gives the patient a little more flexibility.HMOs require that you select a primary care physician (PCP) who is responsible for managing and coordinating all of your health care.<ul> <li>HMO: You must choose doctors, hospitals, and other providers in the HMO network.</li> <li>PPO: You can choose doctors, hospitals, and other providers from the PPO network or from out-of-network. If you choose an out-of-network provider, you most likely will pay more</li></ul>HMO: HMO's will not provide coverage if you do not have a PCP.<ul> <li>PPO: You can receive care from any doctor you choose. But, you will pay more if the doctors you choose are not "preferred" providers.</li></ul>HMO: You will need a referral from your PCP to see a specialist (such as a cardiologist or surgeon) except in emergency situations. Your PCP also must refer you to a specialist who is in the HMO network.<ul> <li>PPO: You do not need a referral to see a specialist. However, some specialists will only see patients who are referred to them by a primary care doctor. And, some PPOs require that you get a prior approval for certain expensive services, such as MRIs.</li></ul> </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Sherita Swinton</td><td width="185">3/5/2013 4:22:16 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>HMOs (Health Maintenance Organizations) consists of a network provider or a primary care provider. The primary care provider manages the patient’s health care needs. If the patient needs to see a specialist, then him/her will need a referral prior to doing so. Often times, the out of pocket costs for HMOs tends to be lower.PPOs (Preferred Provider Organization) offers the patient a group of in-network providers to choose from as opposed to having one primary care provider. This gives patients the right to choose. Not to mention, there is a greater availability of providers with PPOs. However, with PPOs patients tend to pay more.SheritaPeter R. Kongstvedt. <i>ESSENTIALS MANAGED HEALTH CARE 5E VITALBOOKS</i>, 5th Edition., 2007. <i>Bookshelf</i>. Web. 05 March 2013 <<a href="http://devry.vitalsource.com/books/9780763797928/Root/1">http://devry.vitalsource.com/books/9780763797928/Root/1</a>>. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Julie Hicks</td><td width="185">3/7/2013 8:07:01 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Yea, Sherita. I agree the PPO system does provide a wider range of doctors. Some people that use this type of organization generally assume they are paying morebecause they are receiving better or more quality care. This is not always the case. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Sherita Swinton</td><td width="185">3/8/2013 5:44:44 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>Julie,You bring up a very interesting point. Many individuals do feel that they are receiving better, quality healthcare because they pay higher costs for PPOs. The real advantage is that the recipient has the freedom to choose their providers. Not necessarily better healthcare. The higher the costs doesn't always guarantee better care and complete satisfaction.Sherita </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Peru Tuika-Soske</td><td width="185">3/5/2013 9:28:09 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Preferred Provide Organizations (PPOs) is a health plan that has contracts with a network of "preferred" providers which you can chose from.Point-of-service (POS) are plans that combine the features of an HMO and a PPO.HMO and PPO plans differ because with HMO, you must choose doctors, hospitals, and other providers in that HMO network. You cannot look outside of that network. PPO is just the opposite. YOu can choose doctors, hospitals, and other providers from either the PPO network or out of the network.With HMO, you must have a primary care physician or they will not cover it. PPO on the other hand, you can receive care from any doctor of your choice.HMO requires you to be referred to a specialist, with PPO, you do not. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Jodie Knox</td><td width="185">3/6/2013 11:56:27 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Just curious because I have only had personal experience with traditional HMOs, are PPOs more expensive in terms of premiums, copays, and deductibles? I know the cost differences for choosing an out of network provider but if you see in an in-network provider, what is the cost difference monthly, annual, or per visit?It got me thinking that PPOs are probably more attractive to wealthy individuals whereas traditional HMOs are for the less wealthy or for those whose workplace only offers the traditional option such as the military and active duty members.Overall, it seems to me that if it is affordable, that a PPO would be preferable to a traditional HMO. Why wouldn't you want more choices unless it was cost prohibitive?Jodie </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Stephanie Lynch</td><td width="185">3/9/2013 11:15:59 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>Jodie,My experience has been that if you are seeing someone who is "in network" then it's usually inexpensive. As far as copay ect. That varies from plan to plan, just as with any other options. I have only ever had a PPO. But from my experience, I only pick a deductible that I know I can meet.In my old job, I would have to call patients and pre-register them for appointments at one of the hospitals in the system that I work for. As part of the process, if there was an estimate, say for their deductible, I would let them know and explain what it was. You would not believe the number of people who don't know what their deductible is; what their copay is; that there is a difference between copay and coinsurance; what an out of pocket is; and how all of those things are related. I would take the time and explain it to them. I would have people who would have 6000 out of pocket for the year and wonder why their tests were costing so much when they have insurance.This is one topic that people keep themselves stupid about for no reason. As soon as I go my first job that gave me insurance on my own, I made my mom teach me what it all meant. I purposefully pay more out of my checks so that I have a lower deductible and lower annual out of pocket, plus an HSA card to help cover my scripts, co pays, and other medical bills I will have throughout the year.As someone who lives with chronic illness, this is something that I can't afford, both for my health and financially, to screw up to bad. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Antonio Walker</td><td width="185">3/5/2013 10:13:53 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Mrs. Warren,PPOs are health plans that have contracts with a group of preferred providers from which you can select. There is no specific PCP and referrals are not required. A POS plan merges the PPO and HMO plan. A patient can stay in network with a specific provider or choose a provider out of network (without a referral). HMOs stay with providers in network, where as PPO can go in or out of network. HMOs require claims for payment when staying in network where as PPOs do not.  </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Lisa Kieffer</td><td width="185">3/6/2013 2:12:12 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>HMO or Health Maintenance Organization provides employers offer health insurance at a reduced cost by negotiating with doctors, hospitals and clinics (specific). These providers that will be used must have reduced fees for the patients.PPO or Preferred Provider Organization can provide members (employers) health insurance at reduced costs to be billed to their insurance company. Employees have more choices in physicians they see versus being restricted with a HMO. The employee can choose a member or "in network" or non-member "out of network" physicians or facilities. The in network would be the most least expensive.POS or Point of Service where employees can choose their own physician that is on contract with the insurance company for a discounted fee. The employee would see the physician first let's say an internal medicine physician and then if that doctor feels the patient needs to go to a specialist will refer the patient to the specialist. This process ensures the patient the most benefit and the most cost effective. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">David Judkins</td><td width="185">3/6/2013 7:32:23 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>A PPO is a Preferred Provider Organization. The text defines this as a plan that contract with individual providers at a discount for services. It has limited size and usually has some of utilization review system. It may be a risk bearing plan such as an insurance company or it may be non-risk bearing such as a physician sponsored PPO that markets itself to an insurance company.A POS plan is a point of service plan. The text defines this as a plan where members do not have to choose services until they need them. A common use of this plan is that enroll each member in both an HMO system and a PPO indemnity plan. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Nikki Hetzer</td><td width="185">3/6/2013 10:09:16 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td><b>According to <a href="http://www.agencyinfo.net/iv/medical/types/hmo-ppo-pos.htm">http://www.agencyinfo.net/iv/medical/types/hmo-ppo-pos.htm</a>PPO are:</b>Like an HMO, a preferred provider organization (PPO) is a managed healthcare system. However, there are several important differences between HMOs and PPOs.A PPO is actually a group of doctors and/or hospitals that provides medical service only to a specific group or association. The PPO may be sponsored by a particular insurance company, by one or more employers, or by some other type of organization. PPO physicians provide medical services to the policyholders, employees, or members of the sponsor(s) at discounted rates and may set up utilization control programs to help reduce the cost of medical care. In return, the sponsor(s) attempts to increase patient volume by creating an incentive for employees or policyholders to use the physicians and facilities within the PPO network.Rather than prepaying for medical care, PPO members pay for services as they are rendered. The PPO sponsor (employer or insurance company) generally reimburses the member for the cost of the treatment, less any co-payment percentage. In some cases, the physician may submit the bill directly to the insurance company for payment. The insurer then pays the covered amount directly to the healthcare provider, and the member pays his or her co-payment amount. The price for each type of service is negotiated in advance by the healthcare providers and the PPO sponsor(s).<b>POS plans are:</b>A Point of Service (POS) plan is a type of managed healthcare system that combines characteristics of the HMO and the PPO. Like an HMO, you pay no deductible and usually only a minimal co-payment when you use a healthcare provider within your network. You also must choose a primary care physician who is responsible for all referrals within the POS network. If you choose to go outside the network for healthcare, POS coverage functions more like a PPO. You will likely be subject to a deductible (around $300 for an individual or $600 for a family), and your co-payment will be a substantial percentage of the physician's charges (usually 30-40%). </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Managed Health Care Structure Week 1 Thread 2 </b></td><td nowrap="nowrap" width="200">Teresa O'Brien</td><td width="185">3/6/2013 10:52:15 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>A preferred provider organization or PPO (aka participating provider organization) is a managed care organization of medical doctors, hospitals, and other health care providers who have contracted with an insurer or a third-party administrator to provide health care at reduced rates.A point of service plan (POS plan), is a type of managed care health insurance system that is based on lower medical costs in exchange for more limited choice of physicians, but POS also requires that a patient must select a primary care physician (PCP), from within the healthcare network, to monitor their health care. The primary POS physician may then make referrals outside the network, resulting in only some compensation to be offered by the patient's health insurance company.A health maintenance organization (HMO) is an organization that provides or arranges <a title="Managed care" href="http://en.wikipedia.org/wiki/Managed_care">managed care</a> for <a title="Health insurance" href="http://en.wikipedia.org/wiki/Health_insurance">health insurance</a>, self-funded health care benefit plans, individuals and other entities in the <a title="United States" href="http://en.wikipedia.org/wiki/United_States">United States</a> as a liaison with <a title="Health care provider" href="http://en.wikipedia.org/wiki/Health_care_provider">health care providers</a> (hospitals, doctors, etc.) on a prepaid basis.HMO plans differ from PPO plans in the sense that HMOs require members to select a primary care physician – or PCP. This PCP acts as a "gatekeeper" to the patient by directing, or referring, access to medical services. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>PPO plans </b></td><td nowrap="nowrap" width="200">Jose Valderama-Sierra</td><td width="185">3/3/2013 11:08:04 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td><b>Primary care PPOs</b>. Primary care physicians act as gatekeepers for referrals and institutional services. Patients have some coverage for services not authorized by the primary care physician or delivered out of network, but coverage is usually significantly lower than for in-network providers.(Kongstvedt, Peter R.. p. 4).  </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: PPO plans </b></td><td nowrap="nowrap" width="200">Jose Valderama-Sierra</td><td width="185">3/3/2013 11:09:44 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td><b>Prefered provider organizations</b> (PPOs) typically create a provider network for covered individuals by contracting directly with hospitals, physicians, and diagnostic facilities. Unlike HMOs, PPOs allow members to use non–PPO providers, but apply higher coinsurance rates or deductibles for out-of-network services. Many PPOs have utilization management programs.(Kongstvedt, Peter R p. 3).  </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: PPO plans </b></td><td nowrap="nowrap" width="200">Elena Hallars</td><td width="185">3/3/2013 12:10:00 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Some differences to note.....1. Point of service plans combine characteristics from HMOsand PPOs plans.2. More people are covered under PPO than POS.3. POS members do not have to pay deductibles when receiving care.4. PPO members have to submit documentation for reimbursementsthat are out of pocket expenses.Simmilarities......both have networks and by staying within the network members receivemore benefits.Source: <a href="http://www.ehow.com/list_6561246_differences_ppo_health_">www.ehow.com/list_6561246_differences_ppo_health_</a>plans.html. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: PPO plans </b></td><td nowrap="nowrap" width="200">Keniyotha Williams</td><td width="185">3/5/2013 9:13:52 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Elena, I would like to add on the fact that both have networks and that by staying within the network members receive more benefits. I found an article about a Governor from Florida who signed s bill that would allow doctors to receive payments from insurance companies when services are rendered. Blue Cross Blue Shield were opposed to the idea because it didn't give them an opportunity to reject the patients' services. They have to pay regardless. Of course, this interferes with the monies that the insurance companies would like to pay.New Bill Directs Doctors' PaymentTampa Bay WellnessJuly 2009Vol. 24 Issue 7 p. 9 </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: PPO plans </b></td><td nowrap="nowrap" width="200">Brenda Grant</td><td width="185">3/8/2013 4:46:45 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>The copayments for out of network providers are generally much higher, though they will still be covered. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: PPO plans </b></td><td nowrap="nowrap" width="200">Stephanie Lynch</td><td width="185">3/9/2013 11:17:40 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>and they are higher because typically the physicians who are "out of network" get paid at a lower percentage rate of reimbursement. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: PPO plans </b></td><td nowrap="nowrap" width="200">Brenda Grant</td><td width="185">3/10/2013 7:57:34 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>Correct. And the bill still have to be covered some how. So instead of a 80%/20% it may end up being a 60%/40% for cost sharing for copayments depending upon your coverage. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>PPO and POS Plans </b></td><td nowrap="nowrap" width="200">Jorge Amador</td><td width="185">3/3/2013 9:19:08 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>PPO and POS plans are defined as the following:PPO: Preferred Provider Organization which is mainly a group of people that are like doctors, specialists, hospitals etc. who have joined a group of insurance companies list of providers to be able to work together with one another to provide the service seeked by the patient within the insurance they currently have. (Wikipedia)<a href="http://en.wikipedia.org/wiki/Preferred_provider_organization">http://en.wikipedia.org/wiki/Preferred_provider_organization</a>POS Plans: Point of Service Plan which means and relates to having a chosen primary care provider and staying within the network but will be able to go outside the only thing is that the patient is responsible to provide all the paperwork necessary to get the coverage they want. "Members of a POS plan do not make a choice about which system to use until the point at which the service is being used." (Wikipedia)<a href="http://en.wikipedia.org/wiki/Point_of_service_plan">http://en.wikipedia.org/wiki/Point_of_service_plan</a>I believe the main difference is that HMOs are more concentrated on using all in network services and that one has to choose the providers from the list where PPO is a choice as long as the Primary Care Provider is part of the PPO plan "out of network can still be covered".At least that is what I think but I have yet to understand if that is entriely true. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: PPO and POS Plans </b></td><td nowrap="nowrap" width="200">Letitia Armour</td><td width="185">3/5/2013 7:23:17 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Professor Johnson-Warren and Class,Primary Care Physicians plays a major role in the HMO because they determines if the patient be referred or not. This can sometime cause major medical treatment or care problems because if the primary care physicians do not feel it is not feasible to go to an specialist or another referral then, it could be a life or death situation. Of course, this is not always the case because most of the time your primary care physicians know if there are alternatives to get medical care. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: PPO and POS Plans </b></td><td nowrap="nowrap" width="200">Brenda Grant</td><td width="185">3/8/2013 4:56:23 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>I see where you are coming from and yes, it can cause issues if the primary health care provider does not place the appropriate referrals. However, with most HMO's the patient has the right to change his or her primary care provider at any time. So for this situation if a patient felt that he or she was not receiving the care which he or she needed they could change primary care providers in order to receive the appropriate care necessary. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: PPO and POS Plans </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/5/2013 10:13:02 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Thank you Jorge for your post.The POS plan may have better premium rates than any of the preceding types of plans, but this difference has eroded in recent years, probably accounting for the decline in popularity of POS. The ability of the POS plan to manage utilization on the in-network side is at least superior to a nongatekeeper type of plan, but not necessarily so. The POS plan also allows the member to choose to go outside of the network to receive services, albeit at a lower level of benefits; this demonstrates a level of improved access compared to a pure HMO. The disadvantage is that the POS plan does not control costs as well as an HMO. The other major disadvantage is that the POS plan is a bit harder to administer properly, is difficult to capitate, and often requires two licenses to operate.So class let's go out a bit more....What is an Open-Panel HMO? Would this be something that you may want enroll in? </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: PPO and POS Plans </b></td><td nowrap="nowrap" width="200">Guertty Lopez</td><td width="185">3/6/2013 8:18:24 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>An open-panel HMO is a managed care plan that contracts with independent doctors, also called hospitalists, to deliver care health plan member/patients in their own offices. Physicians may contract with multiple plans to care for their members while at the same time caring for HMO members. This is also associated with the IPA model HMO.<i>"IPA (independent or individual practice association) model: Organized system of health insurance and medical care in which an HMO contracts with independent, private-practice physicians or associations of such physicians, who serve HMO members and other patients. Most physicians in the U.S. have contracts with one or more HMO's. Physicians in this model generally are paid on a modified fee-for-service or capitated basis. IPA's are the most common form of HMO</i>"Tufts Managed Care Institute (1998). "Managed Care Models and Products."<a href="http://www.thci.org/downloads/ModelsProducts.pdf">http://www.thci.org/downloads/ModelsProducts.pdf</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: PPO and POS Plans </b></td><td nowrap="nowrap" width="200">Jose Valderama-Sierra</td><td width="185">3/7/2013 7:11:57 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>An open panel HMO is a health maintenance organization that allows individual physicians to participate in the program through the auspices of an independent practice association. A physician who participates in an HMO is this manner is free to see patients who are not connected with the organization and is not committed to taking on a patient simply because he or she is with the HMO. This is in contrast to a closed panel HMO, in which the physician is directly linked to the HMO and is under contract to any and all HMO members who are assigned to the doctor by the organization. the link below shows the type of application that is completed for it<a href="http://www.wisegeek.com/what-is-an-open-panel-hmo.htm">http://www.wisegeek.com/what-is-an-open-panel-hmo.htm</a> </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: PPO and POS Plans </b></td><td nowrap="nowrap" width="200">Sheriker Bellard</td><td width="185">3/6/2013 8:23:19 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>An HMO in which any physician who meets the HMO's standards of care may contract with the HMO as a provider. These physicians typically operate out of their own offices and see other patients as well as HMO members. I wouldnt mind enrolling in a plan like this however I know I would need additional coverage. It gives you the option as of seeing provider as long as they are an approved provider..where in essence you may still have to have a referral in order to see a specialist. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: PPO and POS Plans </b></td><td nowrap="nowrap" width="200">Letitia Armour</td><td width="185">3/6/2013 9:12:03 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Professional Johnson-Warren and Class,An open panel HMO was not part of the original design for a health maintenance approach to healthcare coverage. The concept of the health maintenance organization dates to the early 1970's in the United States. HMO's role is means of providing in network healthcare. Hmo's were formed because consumers demand coverage and out of a need to curb spiraling costs and they formed profit centers. The open panel to HMO allows healthcare professionals to operate independently members.<a href="http://www.wisegeek.com/what-is-an-open-panel-hmo.htm">http://www.wisegeek.com/what-is-an-open-panel-hmo.htm</a>I would only want to enroll in the open panel hmo if the patient have an opportunity to utilize the physicians specialist in the independently HMO network. At my company I work for i have HMO and i like it because I have no deductible. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: PPO and POS Plans </b></td><td nowrap="nowrap" width="200">Antonio Walker</td><td width="185">3/6/2013 9:48:43 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Mrs. Warren, An open Panel HMO is were physicians treat both HMO and private patients. I would participate because the open Panel HMO seems to provide access to a broader array of providers. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: PPO and POS Plans </b></td><td nowrap="nowrap" width="200">Teresa O'Brien</td><td width="185">3/9/2013 10:56:03 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>In an open-panel plan, any qualified physician who accepts the HMO's contract rate is allowed to join as a participating provider; whereas, in a closed-panel plan providers are direct, exclusive employees of the health plan (ex. staff model HMOs). <a href="http://www.ahrq.gov/legacy/about/evaluations/uspstf/uspstfeval5b.htm">http://www.ahrq.gov/legacy/about/evaluations/uspstf/uspstfeval5b.htm</a>Many HMOs now incorporate features of both open and closed-panel plans, so I think it would depend on the details of the contract. This is what makes it so very hard to select the right plan when enrollment comes around - knowing and understanding these details and how it ends up impacting the health care providers you ultimately choose and your checkbook. I think I would probably choose an open panel plan that would accept a qualified physician and not only require exclusiveness. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: PPO and POS Plans </b></td><td nowrap="nowrap" width="200">Nikki Hetzer</td><td width="185">3/6/2013 10:14:39 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>According to Introducation to the Financial Management of Healthcare Organizations, Fifth Edition: an open panel HMO reimburses the physicians either on a fee-for-service basis, often with a discount. It's an HMO that exerts moderate control over physicians by contracting with them to provide care for enrollees. These physicians can also see other patients. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: PPO and POS Plans </b></td><td nowrap="nowrap" width="200">Lisa Kieffer</td><td width="185">3/9/2013 8:00:00 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>An HMO in which any physician who meets the HMO's standards of care may contract with the HMO as a provider. These physicians typically operate out of their own offices and see other patients as well as HMO members.This type of HMO I believe is what I have or at least what my primary care physician is in. Dr. Sheth works for the same company I do so he is an employee also. He see patients in an office with other physicians who work for the company also. I can only see physicians who work for my company. But Dr. Sheth sees patients with all kinds of insurance BUT medicaid. Only the OB/GYN docs are the only physicians who will see patients with Medicaid. Medicare is accepted but not medicaid.Since I really don't have a choice, I have to have this particular kind of health insurance so yes I would have to enroll in it. I am at the mercy of my employer. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: PPO and POS Plans </b></td><td nowrap="nowrap" width="200">David Judkins</td><td width="185">3/10/2013 2:00:49 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>The open-panel HMO is where where any physician who meets the HMO's standards of care may contract with the HMO as a provider. These physicians typically operate out of their own offices and see other patients as well as HMO members.<a href="http://www.superglossary.com/Definition/Health_Insurance/Open-Panel_HMO.html">http://www.superglossary.com/Definition/Health_Insurance/Open-Panel_HMO.html</a>I think it would take more research by the patient it they choose to see the open-panel HMO. Since the physician operates out of their own office and has more of a private setting, as a patient I would seek to find out as much as possible about doctor before I put my health in his hands. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: PPO and POS Plans </b></td><td nowrap="nowrap" width="200">Satchit Ladwa</td><td width="185">3/10/2013 9:21:00 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>POS, or point-of-service, health insurance plans may not be as familiar as health maintenance organizations, or HMOs. But they can give you more health care flexibility while still costing less than the most expensive plans out there. POS plans are a form of managed care offering some out-of-network coverage. So you can cast a wider net for specialists and services. Most Americans enroll instead in HMOs or PPOs, or preferred provider organizations.<a href="http://www.foxbusiness.com/personal-finance/2013/02/19/pos-health-plans-like-hmos-but-more-choices/">http://www.foxbusiness.com/personal-finance/2013/02/19/pos-health-plans-like-hmos-but-more-choices/</a> </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>As managed care changes.... </b></td><td nowrap="nowrap" width="200">Elena Hallars</td><td width="185">3/4/2013 11:42:57 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>As you read about the different types of plans you noticethat each plan along the the timeline adds more managementand control as well as more info which leads us to morecomplex billing and IT systems. As I studied medical billingat harold washington, chicago I see how difficult it is coding newclients vs. old clients and the more complicated a patient's healththe higher the risk for admin errors. The affordable care act willbring more awareness to preventive care as a way to keep costsdown. Friends of mine now have to have wellness visits or theirpremiums will go up. Sounds like a good incenitive to stay healthy. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: As managed care changes.... </b></td><td nowrap="nowrap" width="200">Satchit Ladwa</td><td width="185">3/10/2013 9:17:14 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>From a hospital administrator's point of view, my position would be in favor of managed care because my main goal is "the bottom line". I need to cut costs, stay within rules and guidelines, evaluate treatments/procedures according to coverage plan, get patients in & out at the right time, stay up to date with medical/business/legal news, and so forth. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>HMO vs PPO </b></td><td nowrap="nowrap" width="200">Sandy Williamson</td><td width="185">3/4/2013 5:47:40 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td> Both of HMO and PPO plans are types of networks. HMO stands for Health Maintenance Organization and PPO stands for Preferred Provider Organization. They are not health insurance plans per se, but managed care networks initially designed to control health care costs.If you have a health insurance plan that is administered by a health maintenance organization, then the doctors and hospitals that accept your plan are all a part of the same tight network of providers.You will have to choose a primary care provider that in many ways serves as a gatekeeper for the HMO. It is through your primary care physician that you will be able to get referrals to specialists and having diagnostic tests done. Most non emergency procedures must be preapproved by the HMO through your primary care doctor in order for the insurance benefit to be paid.If you have a health insurance plan that is administered by a Preferred Provider Network, then you can choose any provider within or outside of the network. If you choose to use a doctor that is outside of the network, your coverage for that service is reduced so that it will cost you more out of pocket, but the choice is yours. This is a good example of what we learned in the lecture video for week one.PPO networks are widespread and include a very large portion of all providers across the U.S. and include providers in rural areas.<a href="http://hmovsppo.org/">http://hmovsppo.org/</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Managed-Care Plans </b></td><td nowrap="nowrap" width="200">Tatiania Tabb</td><td width="185">3/4/2013 6:12:44 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>PPO insurance plans also known as Preferred Provider Organization; are insurance plans that allows patients to visit or seek medical attention from any in-network provider without a referral from there primary care physician. Usually; PPO insurance plans are more feasible and convenient for insurance holders with families because they have the access to go to any doctor or take there family member to any doctor in the PPO insurance network if they are covered by the insurance without seeking a referral first from a primary care physician. A POS plan also known as point of service plan; is a plan that is known in the healthcare world as the plan that combines similarities of an HMO and a PPO plan. A POS plan does not give the insurance carrier a option to choose from a provider list. The POS plans requires the insurance holder to pick the system to use when the care is needed. HMO plans differ from PPO plans because HMO plans require a referral in order to receive medical attention. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>PPO </b></td><td nowrap="nowrap" width="200">Fredrick Casteel</td><td width="185">3/4/2013 7:22:00 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>PPO’s are for individuals who want to see their providers without prior approval from their health plan or medical group and do not have to choose a primary care doctor. In a PPO, individuals seek medical attention from a group doctors and providers where individuals pay co-insurance rate or a percentage of their bill. Individuals who have a PPO, they pay a yearly deductible that covers some of your medical bills.http://www.dmhc.ca.gov/dmhc_consumer/hp/hp_ppos.aspx </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: PPO </b></td><td nowrap="nowrap" width="200">Tatiania Tabb</td><td width="185">3/5/2013 1:28:38 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Fredrick, I found your above post very informative and well written. PPO's are great for parents and there families because they are not required to obtain a referral from a pcp in order to receive services from a specialist like a OB/GYN or Neurologist. Do you prefer HMO of PPO healthcare plans for yourself or your family? </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>PPO and POS Plans </b></td><td nowrap="nowrap" width="200">Keniyotha Williams</td><td width="185">3/4/2013 9:54:31 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>PPOs are plans that offers flexibility. Members are free to choose doctors that are not in network, but the deductible that the patient has to pay is a bit more of an out of pocket expense. POS plans are a cross between PPO and HMO. It offers an enhanced insurance benefit if a net-work doctor is chosen. Deductibles are little or non-existent when PCP refers a non-network care provider. When seeking doctors out of net-work, it could cost patient up to 40% of out of pocket expenses.<a href="http://www.ehow.com">www.ehow.com</a>From a personal experience, HMO plans are different from PPO plans in that PPO plans do not need a referral to see another doctor. I remember a few years back when I was involved in a car accident and my lawyer told me about different doctors I could seek. He also mentioned that it may be a problem considering that many doctors do not view chiropractors as "doctors". It was not an issue for me because I didn't need a referral to see a chiropractor (My PCP thought I didn't need to see a chiropractor although I was sore). The biggest difference between the two is that PPO plans allow patients to research and make their own decision on what type and which doctor is available. Perhaps many patients feel comfortable with a certain gender or race of a particular doctor (Many foreigners would feel at ease when finding a doctor from their race; someone that they could relate to). When you are confined to certain doctors within a net-work, it limits your choices. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: PPO and POS Plans </b></td><td nowrap="nowrap" width="200">Elena Hallars</td><td width="185">3/5/2013 1:03:37 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Yes, it really depends on your personal situation in determining what insurance is best foryou and your family. POS can be cheaper but PPO is better because it tames our fears aboutthe uncertainties that our health brings. For the elderly population I choose PPO because of highrisk of hospitalization and need for specialists~ they don't have time for waiting for referrals becausetheir health is fragile. Young people could choose high deductible plans while their healthy as well as healthsavings accounts. It's a balance between savings and quality for all involved. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>PPO </b></td><td nowrap="nowrap" width="200">Fredrick Casteel</td><td width="185">3/5/2013 3:53:28 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>HMO is an organized system of healthcare delivery for both hospital and physician services where care and financing functions are offered by one organization. PPO was a contract directly with the employer through the employer’s health benefit department or indirectly through an insurance carrier to provide health care services from a preselected group of providers. This limited list of providers provided a lower overall cost to the patient. <a href="http://academic.udayton.edu/health/02organ/manage01c.htm">http://academic.udayton.edu/health/02organ/manage01c.htm</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Differences HMO and PPO </b></td><td nowrap="nowrap" width="200">Jorge Amador</td><td width="185">3/5/2013 8:49:59 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>From personal experience this is truly how I learned what would HMO do for my father:During December of last year they decided to change and try out an HMO plan going from Medicare to that, the issue is that my father has ongoing chemotherapy so he needs to keep going in every month and get the medication he needs for it to control his cancer. The biggest obstacle was to select a "Primary Care Provider" that would work with the current doctor he is seeing for the Radiation and Chemotherapy at the hospital he is going to so that way no need to change all that system, my father ended up stopping the HMO before he had a chance to go to the Primary Care Provider and changed back to Medicare due to his medication not being covered like before.After changing later on they received a bill stating that the HMO was not going to pay due to the treatment not being "emergent and not having a primary care provider refer to that treatment" which is incredible due to the fact he has been doing this for years. We are still appealing that decision but that is my personal take on HMO programs, one has to make sure that everything goes thru the Primary Care Provider for services to truly be covered.My question is what would Medicare be designed as? Would it be something more like a PPO plan since HMO most of the time need a primary care provider so I am sure with the readings I can answer that but just curious the classification. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Differences HMO and PPO </b></td><td nowrap="nowrap" width="200">Jodie Knox</td><td width="185">3/8/2013 9:02:05 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Hi Jorge,I am sorry to hear about your father. That is terrible that you have the added stress of insurance administration on top of his cancer. I liked your question about what Medicare is designated as and decided to research it a little bit. I found two websites that were helpful. As I understand it, Medicare allows options for plans that range from PPO to traditional HMOs and depend on out of pocket costs that you want to cover. With the traditional HMO, patients have to find doctors that accept Medicare as insurance. Just like with all of the other factors of an HMO, Medicare follows these rules as well. Medicare also offers PPO options where the out of pocket costs are higher for out of network providers. However, it seems to me that there is an annual cap on how much the patient must pay per year and after that amount has been met, then the insurance covers the rest.Here are the two websites in case you wanted to read up on it. The Medicare FAQ site is helpful for understanding the questions usually asked by new enrollees.Jodiehttp://www.ehow.com/about_5063107_medicare-hmo.htmlhttp://www.medicare.gov/your-medicare-costs/medicare-health-plan-costs/costs-for-medicare-health-plans.html </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>RE: HMO ACT OF 1973 </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/5/2013 10:16:59 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td><b>Modified:</b>3/5/2013 10:18 PM</td></tr><tr><td width="38"></td><td><p align="center">Many of you have mentioned this act in your post. Let's dig deeper---discuss the HMO Act of 1973. What impact has it had on healthcare?</p><p align="center"></p> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: HMO ACT OF 1973 </b></td><td nowrap="nowrap" width="200">Pedro Huertas</td><td width="185">3/6/2013 11:28:14 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td><b>Modified:</b>3/6/2013 11:30 AM</td></tr><tr><td width="93"></td><td> The HMO Act of 1973 had a significant impact in the American Health System. The Act promoted the creation and viability of private HMOs with the injection of federal funds to help develop the industry and subsidize HMO's operational costs. The ACT also required private employers with more than 25 employees to offer the HMO option, which helped promote the sustained growth of the industry. In addition, the Act served as the foundation for other managed care plans such as PPOs and point-of-service plans. Overtime the Act’s initial effect was overshadowed by amendments, other legislations, and the effective development of today's private health care industry.<a href="http://www.ama-assn.org/resources/doc/cms/cmsreport4-a04.pdf">http://www.ama-assn.org/resources/doc/cms/cmsreport4-a04.pdf</a> </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: HMO ACT OF 1973 </b></td><td nowrap="nowrap" width="200">Fredrick Casteel</td><td width="185">3/6/2013 12:47:16 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>The major purpose of HMO Act of 1973 was to stimulate interest by consumers and providers in the HMO concept and make health care delivery under this form available and accessible in the health care market. The Act provided a fixed monthly or annual payment periodically determined and paid in advance for services that were needed to their subscribers.HMO also require an open enrollment period, 1/3 of the policymaking body enrolled in HMO, and allowed reimbursement of out of the area if it was medically necessary before he/she could return in such area with exceeds of $5,000 in any year.<a href="http://www.ssa.gov/policy/docs/ssb/v37n3/v37n3p35.pdf">http://www.ssa.gov/policy/docs/ssb/v37n3/v37n3p35.pdf</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: HMO ACT OF 1973 </b></td><td nowrap="nowrap" width="200">Tatiania Tabb</td><td width="185">3/6/2013 1:38:00 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Professor Johnson-Warren, I believe that the impact that HMO's has had in the healthcare world are huge. I know that HMO healthcare plans were created to save money but I also think that it was created to add some structure to the healthcare world. With the requirements that HMO plans have such as referrals needed to see specialist makes doctor offices follow certain guidelines in order to get paid because an HMO healthcare claim without a referral would not be paid. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: HMO ACT OF 1973 </b></td><td nowrap="nowrap" width="200">Peru Tuika-Soske</td><td width="185">3/6/2013 3:56:00 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>The HMO Act of 1973 was developed to help the U.S health system by providing grants to start or expand HMOs, and removing the many restrictions imposed by individual states, also requiring employers with more than 25 employees to offer a federally-certified HMO to their employees.It was an idealistic approach to help save money and enhance health care delivery to patients while controlling costs. But this Act did just the opposite. Instead, they went from being patient friendly, non-profit organizations and having easy access to medical specialists to making the health care system a for-profit organization putting restrictions on their members. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: HMO ACT OF 1973 </b></td><td nowrap="nowrap" width="200">Sandy Williamson</td><td width="185">3/6/2013 5:21:47 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td><b>Modified:</b>3/6/2013 5:30 PM</td></tr><tr><td width="148"></td><td>I recall a lot of of employees complaining that they had to jump through a lot of hoops just to be treated for anything. They were unable just to go to the doctor and be done with it, or they wouldn't pay the bill. I moved a lot back then and by the 1980's I was living in the Florida Keys trying to turn the place into the Conch Republic and become exiled from the US. But it seemed to me that the idea of a Health Maintenance Organization could of been beneficial for those that were all ready healthy.http://www.ssa.gov/policy/docs/ssb/v37n3/v37n3p35.pdfOn this web site it says that the physician will be paid from the pool of money collected from the group of employees and if the physicians feel the need to charge more for more services he can.It also says that you must pay extra if you are going to get a long term illness it sounds like you are supposed to schedule ahead if you plan on getting more than the common cold. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: HMO ACT OF 1973 </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/6/2013 10:20:45 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Thanks Peru for your post this week.Just for additional thought. Class, Who was Dr. Paul Ellwood and what was his contribution to the HMO ACt of 1973? </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: HMO ACT OF 1973 </b></td><td nowrap="nowrap" width="200">Julie Hicks</td><td width="185">3/6/2013 11:31:45 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>Dr. Paul Ellwood was a "pediatric neurologist" that specialized in a polio during the peak of this disease in the 50's. He was a consultant on the presidential staff (President Nixon). He named the prepaid plans "Health Maintenance Organization." These HMO were a group of doctors that were apart of the prepaid health plan. In this plans the offered different types of quality care for reasonable prices. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: HMO ACT OF 1973 </b></td><td nowrap="nowrap" width="200">Nikki Hetzer</td><td width="185">3/9/2013 10:36:40 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>According to <a href="http://www.burtonreport.com/infhealthcare/managedellwood.htm">http://www.burtonreport.com/infhealthcare/managedellwood.htm</a> Dr. Paul Ellwood was a pediatric neurologist that left the practice of medicine to initiate national health reform. He recognized that the United States Government was becoming more and more involved in the planning and funding of health care as demonstrated by its introduction of "Medicare." Dr. Ellwood, and his associates regarded Medicare as the advent of a disturbing trend towards socialized medicine. Because of this he intended to introduce the "health maintenance organization" as a better alternative to a socialized system. Elwood's goal was to initiate a new direction in health care which would not only provide quality service to the public, but would also contain escalating health care costs by preventing disease and also maintain good health in the population. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: HMO ACT OF 1973 </b></td><td nowrap="nowrap" width="200">Guertty Lopez</td><td width="185">3/9/2013 8:52:37 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>Here's an interesting website: <a href="http://www.managedcaremuseum.com/timeline.htm">http://www.managedcaremuseum.com/timeline.htm</a> It provides the timeline for the history of managed care and Paul Ellwood was certainly part of it. He coined the term "HMO" in 1970. The textbook also states:<i>"The HMO Act of 1973, both authorized start-up funding and, more important, ensured access to the employer-based insurance market. It evolved from discussions that Paul Ellwood, MD had in 1970 with the political leadership of the U.S. Department of Health, Education, and Welfare (which later became the Department of Health and Human Services). Ellwood had been personally close to Philip Lee, MD, Assistant Secretary for Health during the presidency of Lyndon Johnson, and participated in designing the Health Planning Act of 1966. Ellwood, sometimes referred to as the father of the modern HMO movement, was asked in the early Nixon years to devise ways of constraining the rise in the Medicare budget. Out of those discussions evolved both a proposal to capitate HMOs for Medicare beneficiaries (which was not enacted until 1982) and the laying of the groundwork for what became the HMO Act of 1973. The desire to foster HMOs reflected the perspective that the fee-for-service system, by paying physicians based on their volume of services, incorporated the wrong incentives. Also, the term "health maintenance organization" was coined as a substitute for prepaid group practice, principally because it had greater public appeal." </i><i>(Kongstvedt, p. 5-6)</i>So basically, we can see that Dr. Ellwood's influence on the HMO Act had great to do with constraining the medical providers from getting paid so much money from Medicare, as it was based on the volume of services. The more services a doctor provided to a Medicare patient as well as how often they visited the doctor, the more that doctor would get paid. This probably provided for many unnecessary treatment to the patient while many doctors who did not see Medicare patients, were not getting paid as much even though they may have well been performing the same amount of services. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: HMO ACT OF 1973 </b></td><td nowrap="nowrap" width="200">Elena Hallars</td><td width="185">3/6/2013 6:06:37 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td><b>Modified:</b>3/6/2013 6:07 PM</td></tr><tr><td width="93"></td><td>HMO Model Act of 72' and 73'Slow growth/popularityHospitals started looking at discharging as quickly as possible to outpatient, homecare,skilled nursing, etc.The need for case managers as HMO became more popular.1983 social security act amendments to payment for hospital in patient stay from price/dayto flat rate lump sum payment peradmission regardless of length of stay.Medicare part c emerges in 1997 with the balanced budget act.1999 AZ supreme court ruling allowed patients to sue hmo under act of 1973.Physicians were paid bonuses for minimizing care/services/etc.....part of the backlash.Things begin to balance in the 2000s sort of....PPOs still more popular and worth studying.Source: our text </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: HMO ACT OF 1973 </b></td><td nowrap="nowrap" width="200">Jorge Amador</td><td width="185">3/7/2013 9:53:32 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Professor,From what the main impact created by the HMO Act of 1973 is it encouraged the Creation of HMO's and tried to create Healthcare affordable to all and available to more people. It helped fuel the creation of more and more HMO's and improve the way that the Healthcare was at that time and pushed it to become more widely spread to try to get more and more people the ability to have more available resources to the people so they can take care of themselves.http://en.wikipedia.org/wiki/Health_Maintenance_Organization_Act_of_1973 </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: HMO ACT OF 1973 </b></td><td nowrap="nowrap" width="200">Keniyotha Williams</td><td width="185">3/8/2013 10:59:02 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Originally, the HMO Act of 1973 , was a response to the challenge of a way to improve healthcare. The function was to provide healthcare without federal subsidies of the initial period of the Federal support. The impact of HMO has led many leaders to brainstorm of plans to provide healthcare to all that can't afford it. Healtcare was one of the main topics in the presidential debate. It is a concern for many of the citzens and they are putting pressures on the people of power to make a change. For instance, the Kaiser Foundation Health Plan will provide subsidies. Subsidies will be offered for low-income state residents in the state of Connecticut. It was the first subsidy by HMO in the state.Nixon'sNixon's transcript: <a href="http://www.presidency.ucsb.edu/ws/?pid=4092">http://www.presidency.ucsb.edu/ws/?pid=4092</a>.http://articles.courant.com/1992-12-02/news/0000109116-1-subsidy-kaiser-hmas-kaiser-found </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: HMO ACT OF 1973 </b></td><td nowrap="nowrap" width="200">David Judkins</td><td width="185">3/10/2013 2:16:17 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>The HMO Act of 1973 authorized star-up funding and ensured access to the employer based insurance market.The text states the main features of the Act include:-Grants and loans were available for the planning and start-up phases of new HMOs as well as for service area expansions for existing HMOs.- State laws that restricted the development of HMOs were overridden for HMOs that were federally qualified, as described later.-And the dual choice provisions, which required employers with 25 or more employees that offered indemnity coverage also to offer two federally qualified HMOs, one of each type: (1) the closed panel or group or staff model and (2) the open panel or IPA/network model, if the plans made a formal request (Kongstvedt 6)This helped to improve the quality of the HMO programs. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>RE: Week 1 PPO, POS, and HMO </b></td><td nowrap="nowrap" width="200">Brenda Grant</td><td width="185">3/6/2013 6:56:09 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>PPOs or Preferred provider organization create a network of hospital, physicians, and diagnostic facilities which are covered. The direct difference between and PPO and an HMO is that with a PPO a client is able to utilize a non network provider with a higher copayment applied.Point of service allows the client to choose what type of coverage will be used for a particular instance. Additionally, there is a primary care provider or "gate keeper" who directs the patient's care. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>What's Your Plan? </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/7/2013 11:15:17 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td><p align="center">If your employer offers healthcare benefits, specifically a managed-care program, take a moment to share with the class your experience(s). Do you like your coverage? What would you improve?</p> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: What's Your Plan? </b></td><td nowrap="nowrap" width="200">Julie Gildemeister</td><td width="185">3/8/2013 9:54:03 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>My employer contracts with United Health Care to provide a PPO for retail employees. It is a very broad based network, and so far all of my providers are within the network.For the most part I'm a pretty health person. However, last year I had a chronic cough that wouldn't go away - it became very bad in June. My PCP initially suspected asthma and prescribed the usual asthma medications. However I didn't show much improvement, so she sent me to a pulmonologist. Long story short, I had to undergo invasive thoracic surgery in order to obtain diagnostic samples, and have a diagnosis of hypersensitivity pneumonitis. Some of you may know it better as "farmer's lung." In any case, I now have outstanding medical bills with four different providers that I'm trying to pay off. However, if it wasn't for the UHC PPO, my financial situation would be much, much worse.I actually like this plan better than BCBS - I had an individual plan with them in the past and hated how much the premium went up over the seven years I was with that plan - from about $520 every two months to nearly $800! My current plan has a much lower premium, and it's taken out of my paycheck pre-tax.I like the coverage I have with the current plan. I also like how proactive UHC is with managing our health. I got a call from a UHC nurse to discuss asthma management. While technically it's not asthma, the treatment and symptoms are very similar, and my veterinary experience tells me that managing this disease is the same as managing asthma. I appreciated the support I got from UHC in providing education to understand the disease and how to live with it. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: What's Your Plan? </b></td><td nowrap="nowrap" width="200">Jorge Amador</td><td width="185">3/8/2013 11:08:54 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Professor,Personally the plan I have is very good when it comes to the Premiums due to having a Union type of job so being Unionized has its benefits and one so far is that the Premiums for Insurance is low and the insurance is good. Recently I have had to use it more especially with my wife's pregnancy and it has been great since they cover most services at 90% in Network and I try to always keep in network after the Deductible is Met which is very good since it currently is $445 and the Maximum Out of Pocket is: $990. I currently pay about $120 but that is dropping in April to $81/month before Taxes. The healthcare provider that we have is United Healthcare and it has been that since I have been at the job for almost 5 years. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: What's Your Plan? </b></td><td nowrap="nowrap" width="200">Antonio Walker</td><td width="185">3/8/2013 4:44:16 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Mrs. Warren,I prefer to have a PPO because I am not limited to a select group of providers. However, the HMO fits well within my budget. Although the providers are limited, I do appreciate the rapport that is established with regular providers. My plan is to switch to PPO, once I graduate and receive an increase in income. In addition, flex spending accounts are an option because they are like shopping for services as needed. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: What's Your Plan? </b></td><td nowrap="nowrap" width="200">Sherita Swinton</td><td width="185">3/9/2013 5:17:16 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Antonio,I agree with you. Currently, I have a PPO. I love the limitless selection of providers, but it is a bit costly on the pocket. I definitely find it suitable to take advantage of the flex spending account. I've never used it before. But I am grateful that I have it. It helps with those little expenses.Sherita </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: What's Your Plan? </b></td><td nowrap="nowrap" width="200">Brenda Grant</td><td width="185">3/8/2013 5:13:39 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>I currently use Tricare Standard which is categorized with Tricare as a Fee-for-service insurance. I do pay monthly premiums. The insurance is phenomenal. There is a $150 cap on copayments. This includes outpatient visits, pharmacy, or anything, optometry, or anything else which we would pay a copayment for. This is per family, not per family member. Once the cap is met, I no longer pay copayments for the rest of the year. The copayments are very small. Generally $15 for an office visit. Medications range between $3 and $22. The only medication which I pay a $22 copayment for is my son's antirejection medication which is $5,000 with out insurance per month. Not too bad. I do not need to have a referral if I want to see a specialist as long as the specialist accepts tricare. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: What's Your Plan? </b></td><td nowrap="nowrap" width="200">Nikki Hetzer</td><td width="185">3/9/2013 11:03:25 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>I had great coverage for Kaiser with both my previous employers. The cost was $0 (for just me) a month and the copayments for each visit were $15. Everything was covered 100% besides a copayment of $100 for a Emergency room visit and $150 for a hospital stay. The current employer has horrible coverage even for Kaiser. It costs $80 a month for just the employee. There is a $3000 deductible and only after that is fully met 80% of the services are covered. I switched immediately to my husbands insurance (who has great coverage for both HMO and PPO). I was so surprised with my current employer's plan options. Coming from Germany and then having great coverage with both my previous employers I was stunnded. The HR person at my current employer told me after that is was just so pricey for them (being a smaller company) and by having the deductible that has to be met first they encourage employees to take charge of their health and really think about before going to the Doctor or getting a procedure done. I understand that it can be very hard for a smaller company to provide healthcare but a plan like that can put a huge strain on some of the employees. Having to pay $3000 before having a percentage covered means for the healthy population to basically pay for all services themselves and for the unfortunate ones that might have an illness or accident having to pay 20% of let's say a $50,000 bill or more is huge.....Of course I would recommend providing better plans with no deductibles and full coverage but in their case they simply can not afford it. The smaller the company the worse plans they can negotiate. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: What's Your Plan? </b></td><td nowrap="nowrap" width="200">Brenda Grant</td><td width="185">3/9/2013 6:10:59 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Wow. That is insane! I could not imaging having that high of a deductible. Most of my adult life I have been covered under Tricare. I am currently facing leaving the military and attempting to find a plan which will have similar benefits. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: What's Your Plan? </b></td><td nowrap="nowrap" width="200">Sheriker Bellard</td><td width="185">3/9/2013 4:13:54 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>My employer does offer me healthcare insurance however, just having coverage is great opposed to so many individuals do not have coverage. My plan offers a VERY high deductible which is the worst - in the amount of $2500 for individual , $5000 for family. I dont pay a lot for health insurance and I am assuming this is the reason why. We have a HSA which my employer puts money in the account every 2 weeks and so do I. This is suppose to help to offset some of the expenses incurred due to the high deductible. I do get better rates when I go to see doctors within my network , so I tend to use the physicians in network. The only issue with this plan is the deductible and many employees do complain on our employee satisfaction survey and nothing seems to change however our premiums dont go up every year like some employers tend to do. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: What's Your Plan? </b></td><td nowrap="nowrap" width="200">Nikki Hetzer</td><td width="185">3/10/2013 5:01:06 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>I know- we all complained with our company's plan too and nothing is ever changed. I am lucky enough to be able to switch to my husbands insurance but many can not do that and have to have their whole families on it. The HSA doesn't really help unless you were able to save for a long time. But if you just started you have to cover everything yourself first. Eventually I think you can reimburse yourself for the costs in the past from the HSA (once you have enough money in it) but it is still so inconvenient. I wonder if some companies do that to discourage employees going to the doctor a lot.... </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: What's Your Plan? </b></td><td nowrap="nowrap" width="200">Peru Tuika-Soske</td><td width="185">3/9/2013 5:49:22 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Like my classmate Brenda, I also have TRICARE, which is a managed care type of health care program. I have been with TRICARE for many years and have had no complaints. My family and I receive the care we need, when we need it and are able to see a specialist when needed. We can also chose to be seen at a military treatment facility (MTF) on base or a local hospital of our choosing as long as they except TRICARE.This website pretty much covers TRICARE benefits, plans and other questions you may have.<a href="http://www.tricare.mil/Welcome/Plans/Prime.aspx">http://www.tricare.mil/Welcome/Plans/Prime.aspx</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: What's Your Plan? </b></td><td nowrap="nowrap" width="200">Pedro Huertas</td><td width="185">3/9/2013 9:14:57 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>I currently have <a href="https://www.avmed.org/index.aspx">AvMed</a> (HMO) State of Florida employee health plan. My executive management position entitles me to a reduced monthly premium ($30 family coverage), which is an amazing deal. The plan has a co-pay of $20 for primary care and $40 for specialty care (no referral needed). The network has a wide range of provider and service options. Preventive care is included as well as many discounts for wellness services. I am satisfied with the service so far as I have not encountered any problems so far. The plan represents a great value with above average coverage and options that are essential to me. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: What's Your Plan? </b></td><td nowrap="nowrap" width="200">Stephanie Lynch</td><td width="185">3/10/2013 7:58:40 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>I love my benefits package. Since I work for a healthcare provider, they take pride in making sure that we get really good benefits. I have heard that what we have now isn't anything like what they used to have but I like what we have. I get a great discount at our pharmacy, and if I get my tests done at our facilities I get a bigger discount and in most cases the test is covered at 100%. I know other patients that I had to talk to in the past would have had to pay for things like an echo or even the nuclear medicine test I just had a couple of weeks ago. For me they were covered at 100%.I have dental and vision as well. The other nice thing is that since I work in healthcare my boss has been great about when I was first diagnosed with my seizure disorder and narcolepsy and more recently with all the stomach problems I have been having. I am not normally one to be sick and I go out of my way to work hard. So I feel bad when I can't pull my weight at work. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: What's Your Plan? </b></td><td nowrap="nowrap" width="200">Lisa Kieffer</td><td width="185">3/10/2013 9:23:30 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>My benefits are $30 doctor visits ONLY Ochsner physicians and Ochsner hospitals. Prescriptions are $150 yearly deductible then $15 generic and $30 for brand but could be as high as $50. Starting in April if you take medication every day, you will no longer be able to go to retail pharmacy you must go through the mail order at a 90 day supply. Costs will be anywhere from $30 to $125 depending on the medication. Specialists are $40, lab, anything in the radiology department (MRI, CT, X-ray is free). ED vists are $200, Hospital stays are $150 a day for 3 days and after 100% covered. Physical rehab is $30 a session which i still think is high. I broke my shoulder last year and spent like $400 on rehab services to get my arm back. Premiums are roughly $65 per person per pay check with vision and basic dental care.So how does my plan stack up? I am with Humana by the way!! </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Let's Talk About EPOs </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/9/2013 7:00:19 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td><p align="center">As we continue our basic discussion on managed care, provide an example of an EPO.</p> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Let's Talk About EPOs </b></td><td nowrap="nowrap" width="200">Julie Gildemeister</td><td width="185">3/9/2013 8:41:44 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>A little online research shows that there are still EPOs existing.According to Kongstvedt (p.26), EPOs, or exclusive provider organizations, are networks of physicians that provide care to members of that plan, much like a PPO. However, the plan will not cover care for out-of-network providers - any member going out of the network will have to pay full costs of that care. Some EPOs have gatekeeper providers that authorize specialty care, much like HMOs; however, unlike HMOs, which are regulated under HMO legislation, EPOs are regulated by insurance legislation or ERISA (in the case of self-funded plans).There are some advantages of an EPO network. Typically they have the lowest premiums or self-funded plan costs. They provide maximal utilization of resources. And the gatekeepers provide appropriate referrals to needed specialists. Physician Care in Michigan offers such a plan, covering most of the state of Michigan.References:Kongstvedt, P. R. (2007). <i>Essentials of Managed Health Care</i> (5th ed). Sudbury, MA: Jones & Bartlett.<a href="http://www.physicianscare.com/content/public/default.aspx?id=333" target="_new">Physicians Care EPO</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Let's Talk About EPOs </b></td><td nowrap="nowrap" width="200">Sandy Williamson</td><td width="185">3/9/2013 6:20:23 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>EPOs are similar to HMOs, in that both types of plans require policyholders to see in-network doctors, and do not reimburse policyholders if they visit non-network providers. The differences are that EPO rates are negotiated based on services, while HMOs are determined by on a capitulated, or per-person basis; EPO providers are only paid for services provided (HMOs receive monthly payments from carriers); and the premiums for EPOs are generally cheaper than HMOs. EPOs are structurally similar to PPOs, but EPO members cannot file claims for non-network office visits, which PPO and POS plans allow.EPOs are beneficial because of their low cost - health insurance carriers can negotiate low premiums and co payments with their providers because they can guarantee that policyholders will visit network doctors only. EPO networks are also better suited for rural areas, which larger HMO networks have trouble covering. EPOs also help their members resolve their conflicts with care providers.The main disadvantage of an EPO is that it is quite restrictive. The network of doctors tends to be smaller than in HMOs, and it is nearly impossible to see an out-of-network provider without having to pay all of the medical fees out of your own pocket.http://www.medhealthinsurance.com/epoplan.htmIt says that this type of insurance works well in the rural setting, but it sure is very restrictive, so I guess everyone would go to the same Doctor in the local town. I don't believe this would be the kind of insurance that would work for me and my family. My mother has 38 different diagnosis right now, a EPO would never work for her she needs specialists of all kinds.  </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Let's Talk About EPOs </b></td><td nowrap="nowrap" width="200">Sheriker Bellard</td><td width="185">3/10/2013 5:46:35 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Julie can certainly understand a patients frustration especially if they find out that after they have an established doctor and when joining an EPO they cannot see they doctor any longer unless they want to continue to pay out of pocket for services being rendered. This can be quite frustrating. I can remember when I worked for an organization that was an EPO , we had great benefits though. We were able to see a nurse practioner that provided us with our visit and medication for $5.00. Even though I could not see my regular doctor, unless I found an doctor that was part of the EPO this option saved me a alot of money. I wasn't all that bad . :-) </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Let's Talk About EPOs </b></td><td nowrap="nowrap" width="200">Keniyotha Williams</td><td width="185">3/10/2013 10:23:18 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Julie,I would like to add something that I researched about EPOs. They are not legal in every state. They are not recognized by the federal law. States that have allowed them have made regulations for the EPOs. These plans are better suited for individuals that are healthy and don't need to see a specialists that may not be offered within the network. The plan would most be beneficial to individuals living in rural areas where HMO do not reach.<a href="http://www.ehow.com%3EHealth">www.ehow.com>Health</a> Care & Insurance </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Let's Talk About EPOs </b></td><td nowrap="nowrap" width="200">Julie Hicks</td><td width="185">3/9/2013 8:00:00 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>An example of an EPO is the Anthem Blue Cross (Blue Cross of California). Their plan works by selecting a doctor based of the county that you live in. They have a number of pharmacies in the are to choose from for prescriptions like CVS, Rite Aid, Walgreen, Etc. The costs of prescriptions usually range from $5-$15. Their customer service lines are available for t least 12 hours per day, fives days a week. The services offered to children are hospitalization when necessary, wellness exams, dental care, eye exams, laboratory and radiology is also covered, along with speech and occupational therapy. THe premiums for a family per month is less than $72.http://www.healthyfamilies.ca.gov/HFProgram/FAQS.aspx#howsoon </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Let's Talk About EPOs </b></td><td nowrap="nowrap" width="200">Jose Valderama-Sierra</td><td width="185">3/9/2013 8:33:11 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>https://www.priorityhealth.com/member/plans/group-plans/hmo-planAt Priorty Health the offer EPOs:EPO (exclusive provider organization) is a group health insurance plan that offers coverage very similar to our HMO, and some benefits may be added or deleted by your employer. Both plans combine great medical benefits with cost savings by ensuring that you get all the health care and medical services you need, but none that are unnecessary.<ul> <li>You get all your care from health care providers in your plan's network.</li> <li>If you go to a doctor, hospital or pharmacy that's not in your plan's network, you will have to pay the full cost of your treatment.</li></ul> </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Let's Talk About EPOs </b></td><td nowrap="nowrap" width="200">Nikki Hetzer</td><td width="185">3/10/2013 5:06:20 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>According to <a href="http://www.ehealthinsurance.com/health-plans/epo/EPO">http://www.ehealthinsurance.com/health-plans/epo/EPO</a> EPO stands for "Exclusive Provider Organization" plan. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside the network for care. There are no out-of-network benefits.Benefits to an EPO are:Not having to get a referral to see a specialist.You can receive a much lower negotiated rate with an EPO plan than you would with an HMO or PPO plan. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Let's Talk About EPOs </b></td><td nowrap="nowrap" width="200">Teresa O'Brien</td><td width="185">3/10/2013 11:23:28 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>EPOs provide a health insurance option that falls in between HMOs and PPOs in terms of price and access to health care services. It also may be less expensive for those who are not turned off by some of the restrictions. It is considered a subset of preferred provider organizations, but it does not include reduced fees for out-of-network care. A PPO requires a health insurance company to pay for some medical tests and other hospital costs that a patient receives, regardless of network affiliation, an EPO does not. A patient will need to pay for any expenses incurred that were not approved by an in-network doctor and performed at an affiliate institution. Last year I had an EPO plan, but this year my plan is an PPO/HSA. I do like not having to see a doctor to get a referral to a specialist, but I do have a general GP and an OB for just regular checkups. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Let's Talk About EPOs </b></td><td nowrap="nowrap" width="200">Pedro Huertas</td><td width="185">3/10/2013 6:17:20 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>EPO health plans are similar to PPOs, but with non-network restrictions. The plan offers cost saving advantages, but with significant limitations. For example, some EPOs offer zero copay for routine visits, which sounds like a very good deal if compared to those of HMOs. The EPO plan administrators are able to provide low cost services because they negotiate lower prices with providers in exchange for a guaranteed number of patients. In addition, the plan administrator handles all claims and disputes within the network. On the other hand, the cost savings result in limited options and the risk of having to cover costs associated with services provided outside the network. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Let's Talk About EPOs </b></td><td nowrap="nowrap" width="200">Antonio Walker</td><td width="185">3/10/2013 11:19:03 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Mrs. Warren,EPOs are managed care plans structured as a combination of HMOs and PPOs. EPO plans can see network providers, for low cost. However, EPOs have no stipulation for coverage of health care outside the EPO network. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Managed Care </b></td><td nowrap="nowrap" width="200">Satchit Ladwa</td><td width="185">3/10/2013 9:12:27 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>In general, managed care seeks to utilize resources in a more efficient, cost-effective way, create accountability for healthcare professionals, and also lead to better patient outcomes. Potential downsides of managed care would include extended waiting period for appointments, co-payments, limited services covered, and lack of allied healthcare usage,According to About.com, there are significant differences for consumers to consider when deciding whether to select an HMO plan or a PPO plan. In an HMO, you must choose doctors, hospitals, and other providers in the HMO network. In a PPO, however, you can choose doctors, hospitals, and other providers from the PPO network or from out-of-network. If you choose an out-of-network provider, you most likely will pay more.http://healthinsurance.about.com/od/understandingmanagedcare/a/HMOs_vs_PPOs.htm </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Managed-Care Plans </b></td><td nowrap="nowrap" width="200">Latia Phelps</td><td width="185">3/10/2013 10:13:24 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>There are many differences between HMO and PPO plans including options and benefits offered to those utilizing the plan. Many people and companies use either plan due to the cost and doctors within the local network. The differences between the two are based primarily on choices. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Week 1 Thread 2 Wrap Up </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/10/2013 10:29:48 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>What plan should I pick at open enrollment? It seems that many of you have picked plans based on various reasons and it is always an individual choice. However, there may be some market situations where a certain type of managed care plans be the preferred model.A market with relatively few PCPs and a concentration of population is theoretically better for a closed-panel HMO than the reverse; in reality however, there are fewer closed panel HMOs now than there were ten years ago, and no new ones have been started. If PCPs are in great abundance (which is still not common as we discussed) or if the market is widely scattered (such as in a semi-rural area), then a closed panel will have a more difficult time succeeding. PPOs are relatively easy to create and may do well in a market that does not have a high level of penetration by a service plan. If priced well POS can do well in most markets where there is an existing HMO to form the network; POS is more difficult to successfully operate when combined with a closed panel HMO because there is more opportunity for members to go out of network.As we viewed the various plans offered to our classmates we could see the diverse plans regardless of the employer. We also have to look at the location of the person and what may be offered in some rural areas of the United States compared to urban/city areas.Once again, I hope you have a great week 1 of class and it's time to kick off week 2. Good Luck and see you in the threads! </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table>
https://www.examtutorials.com/course/hsm-546-w1-dq2-managedcare-plans/

Front 2

About ExamTutorials?

Back 2

Examtutorials.com is a commerical website helps the students in assignment solutions.

Front 3

Why you choose Examtutorials.com?

Back 3

High Quality, Fresh Online Study and more