Features of Private Payer and Consumer-Driven Health Plans
The following reading is to familiarize the reader with private payer plans and types of consumer-driven health plan (CDHP) accounts. Private payer plans such as PPOs, HMOs, and Group HMOs are the most popular but there are also others to consider when making decisions on health coverage, which are IPAs, POSs, and Indemnity plans. The CDHP accounts are made “for the consumer” and therefore consumers (patients) have a say in what kind of plan they wish to have and sometimes consumers can build their own health plan according to their financial situations with savings account options. After reading this information, the reader will have a clearer idea of the options available through health care coverage. Preferred provider organizations (PPOs) are based on membership to a specific health care provisions arrangement. As part of the PPO, the provider participates in this arrangement providing patients with services guided by discounted fee-for-service. This type of service is at a discount from their normal physician fee schedules. Other features of this plan include either a lower premium and higher deductible or visa versa. Copayments are also included in this plan and there could be an annual out-of-pocket deductible. Patients also have the choice of their providers although out-of-network providers will cost more on the patient’s part than provider’s in-network. One thing to remember though is that all non-emergency services require pre-authorization (Valerius, J., Bayes, N., Newby, C., & Seggern, J. (2008). According to WiseGEEK.com, “Most PPOs have a preferred provider list, much like the HMO provider list. Usually, seeing someone on the list means less expense. In fact, the PPO basically has an HMO component and network built into it” (para.6). Health maintenance organizations (HMOs) are state licensed and therefore are a lower cost health plan. Of course, because of less expense there are guidelines that are more stringent and fewer providers from which to choose. All members have a primary care provider (PCP) chosen from within the network providers listed. Only in emergency circumstances can out-of-network providers be used, period. HMOs were implemented for patients to cover basic health issues requiring visit copays and annual premiums but as with progress, basic services have become more expensive, so now certain changes such as co-insurance and deductibles are required for some benefits concerning either family coverage or employer-sponsored HMOs. One other feature that is important to mention is preventive care services and wellness services as well as disease management. Some examples of this are Prostate cancer screening (age 50+), Cervical cancer screening (age 21+), and breast cancer screening (Valerius, et al 2008). In reference to the features of group HMOs, InsureLane network states the following: Some of the attractive features of HMOs include:
No deductibles. Most HMO plans have no deductible — so your employees aren't stuck with huge — and annoying — out-of-pocket costs. Large provider networks. Most HMO plans have statewide networks that include several thousand doctors — so finding a conveniently located provider is easy. Monitored care. The HMO “pre-approval” process makes sure that care is being used properly… and that helps make sure your premiums don't skyrocket (HMO Advantages para.1). Group or network HMOs are plans that are contracted with multiple physician groups. The members visit and are rendered medical care in a HMO-owned facility. This type of facility houses there own physicians. There are also facilities that treat non-members. Providers are paid on a “per member per month” (PMPM) capitated rate for each subscriber that is assigned to them for primary care services. Other providers hired work under either an episode of care (EOC) option or a subcapitation agreement (also PMPM based) (Valerius, et al 2008). Another type of...
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