HMOs
-offer comprehensive health care services to members for a fixed monthly fee by contracting with or employing physicians, hospitals, and other health care professionals to provide medical care to enrollees.
a, c, e
In regards to HMOs, select all that applies:
a. coverage outside of network is not covered
b. patients are fined if they use providers outside of network
c. utilizes a gatekeeper (PCP) to coordinate medical needs
d. coverage outside of network is covered, but costs more
e. providers are placed at financial risk in some capacity
staff model
_______ is a type of HMO characterized by direct ownership of healthcare facilities and direct employment of physicians.
physicians can only provide care to patients in HMO they are contracted with; staff model
Describe a closed panel plan and which type of HMO does this fall under?
c
Which form of HMO covers the physicians salaries?
a. Group model
b. Network model
c. staff model
Group Model
- a type of HMO characterized by contracts with large, multispecialty groups offering services exclusively to the HMO on a capitated basis
-physicians are not paid on salary, instead take on financial risk through contracts
Network Model
-contracts with several large multi-specialty groups for services
-open-panel
-networks receive payment under capitation and they, in turn, pay physicians under a variety of mechanisms
Independent Practice Association (IPA)
-usually a very small group of physicians or an independent practice
-can see patients not enrolled in HMO
-for patients under HMO, providers may be reimbursed on discounted fee-for-service
Open Access HMO
-members may access any provider in the HMO without going through a PCP
-physicians share at least some level of risk for costs
Preferred Provider Organizations (PPO)
-affiliations of providers that seek contracts from insurance plans
-usually have nonexclusive arrangements with PPO; can see patients from other plans
financial incentive
PPO provide ________ to patients so they will receive care from providers in the preferred network.
HMOs
What is typically seen as more restrictive by patients, PPOs or HMOs?
Point of Service Plan (POS)
-functions similarly to HMO in that you pick a PCP who manages and coordinates your care within network.
-different in that each time you need health care you can either decide to stay in or out of network
managed health insurance
-includes traditional indemnity and service benefit plans that utilize cost controls
-employers are moving away from plans like this