Sunday, May 8, 2011
Features of Private Payer and Consumer-Driven Health Plans
There are several types of private payer plans including preferred provider organizations (PPO’s), health maintenance organizations (HMO’s), and point of service (POS). Indemnity plans would cost the most for employees and they usually choose a PPO plan. A trend that is gaining popularity with employees and employers is the consumer driven health plan (CDHP) that has a high deductable combined with a funding option of some type. All of the plans have unique features for coverage of services and financial responsibility. The PPO plan is the most popular of all of the plans that doctors, hospitals and clinics, and pharmacies contract with to provide services to the insured patient. The main feature of the PPO is that they pay the participating doctors a discounted fee for service based on their fee schedule. PPO plans offer a low premium with a higher deductable or a high premium with a lower deductable. At the time of service, the patient must pay a copayment and have a yearly deductable to pay out of pocket. If a patient sees a doctor outside of the network without a referral, the plan will pay less and the patient is responsible for the remainder of the fee (Valerius, Bayes, Newby, Seggern , 2008). The HMO plan has the strictest guidelines and the least amount of providers and is licensed by the state. Patients must see the doctors in their network in order for coverage, except in the case of an emergency. Providing the basics needs for service with an annual premium and copayment at the time of the visit, is the original design for the HMO plan. There are services the HMO plan covers like preventive and wellness checks as well as disease management. However, in order for complete coverage the enrollees must see a doctor that offers an HMO plan (Valerius,...