Florida Health Insurance
The managed health care system is aimed at controlling costs by assigning a set fee for services to doctor’s visits, medical testing, and surgical operations.
Managed health care stresses the concept of preventive care. In a managed care system, the doctor is usually paid a specified amount or a set monthly amount for each patient, this is called capitation. Managed care limits doctors’ income.
Managed care is made up of the following:
Health Maintenance Organization (HMO)
- Preferred Provider Organization (PPO)
- Point of Services plan (POS)
Health Maintenance Organization (HMO)
HMO members pay a monthly fixed dollar amount which gives them access to a wide range of health care services such as doctor visits, and hospitalizations. In many cases, members also pay a predetermined amount, or co-payments, for each doctor or emergency room visits and for prescription drugs. HMO Members must use the services offered by providers from within a network, which may include doctors, pharmacies and hospitals under contract with that particular HMO.
Some HMOs offer an “Open Ended” system which offers the member the ability to see a provider who is not part of the HMO network, but the patient must pay any additional costs.
HMOs make health-care available to more people and emphasizes on prevention resulting in early diagnosis and increase health-care savings. However, some of the critics say:
Patients are greatly limited on the doctors and specialists they can see, because they can only see those who are part of the network.
Many complaints (and lawsuits) have arisen over the HMOs’ refusal to approve serious treatments, and over the concern that the organizations will hold back on care in order to increase the bottom line.
Preferred Provider Organization (PPO)
A PPO offers another kind of provider network to meet and the health care needs of consumers.
The insurance company contracts with a group of health care providers to control the cost of providing benefits to consumers. These providers charge a lower than usual fees because they require prompt payment and serve a greater number of patients. Consumers usually choose the health service provider, but the insured will pay less in coinsurance with a preferred provider than with a non preferred provider.
Each member will have a yearly deductible to pay out of his/her pocket, before the insurance company will start paying medical expenses.
If the Insurance company offers an 80-20 contract, the insurance usually pays 80% of medical expenses, for the in-network doctor, with the patient responsible for the remainder of the bill (ie: 20%). If the person wants to see an out-of-network provider, the insured may do so without permission (referral); but the deductible for out-of-network services may be higher and the percentage the insurance company portion of responsibility will be lower (ie:50-50). In other words, the patient will be responsible for a greater part of the fee. This encourages the people insured with a PPO to use providers within the network.
Even though the out-of-pocket expense for the patient is higher with a PPO, PPO includes the flexibility of seeking care with an out-of-network provider if so desired
PPO networks have prescription services which provide prescription drugs at a reduced cost.
PPO coverage and will often include more providers, and covered more medical services then HMOs.
Point of Service Plans (POS)
Point of service plan is a hybrid between an HMO and a PPO. Point of service plans combines some aspect of an HMO and PPO plan.
In a POS plan, the insured member has the possibility to go and see a provider outside-of the network. However, every time the member goes out of the network, the member will incur extra expenses. The POS plan provides less coverage for Healthcare expenses provided outside the network than for expenses provided inside the network. The POS plan usually requires the insured to pay a deductible and coinsurance costs for medical care received outside the network similar than those incur in a PPO.
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