An Alternative To Indemnity Health Insurance And Managed Care
For a long time now people have felt trapped between choosing a traditional indemnity health insurance plan (offering a wide range of choice and high degree of security in the event of an accident or serious illness at a relatively high cost) and a managed care plan (focusing on preventative medicine with severely limited choice but at relatively low cost).
It is however now possible to some extent to enjoy the benefits of both indemnity health insurance and managed health care through a variation on the original managed health care model provided by the Health Maintenance Organization (HMO) in a plan known as a Preferred Provider Organization (PPO) plan.
In essence a health insurance PPO HMO plan is an HMO which means that the insurance company establishes a network of health care providers and, in exchange for a reasonably low cost, will encourage, or in some instances require, plan holders to seek treatment within the HMO’s network. Normally, where treatment is sought outside of the HMO’s network much, if not all, of the cost is borne by the plan holder however, in the case of a PPO, the rules for plan holders who want to seek care outside of the HMO’s network have been relaxed.
An HMO assigns a plan holder to a particular doctor or primary care physician (often known as a "gatekeeper") and the plan holder must go through the primary care physician in order to receive treatment. For example, if the plan holder wants to see a specialist then he or she must be referred by the primary care physician and may or may not have a say in which specialist they are referred to.
However, in a health insurance PPO HMO plan no primary care physician is assigned and so no referral is necessary. Plan holders are free therefore to seek treatment through a specialist who is not a member of the HMO’s network if they wish to do so.
Naturally there are cost implications to this choice and plan holders will normally have to pay more for treatment with a doctor or in a facility outside the HMO’s network. Unlike the HMO model however the PPO now gives plan holders the choice.
In essence, PPO individual health insurance coverage provides plan holders with the low cost benefits of the HMO but also provides the option to elect for the greater choice, albeit at a higher cost, of indemnity health insurance when it suits the plan holder.
It is no surprise that today traditional indemnity health policies are rapidly disappearing and that there are now twice as many people enrolled in PPOs as there are in HMOs.
Individual health medical insurance quotes - PPO coverage
Competitive advantage: A factor, such as the ability to demonstrate quality, that helps a managed care organization compete successfully with other MCOs for business.
Employment-model IDS: An IDS that generally owns or is affiliated with a hospital and establishes or purchases physician practices and retains the physicians as employees.
Peer review organizations (PROs): According to the Balanced Budget Act of 1997, organizations or groups of practicing physicians and other health care professionals paid by the federal government to review and evaluate the services provided by other practitioners and to monitor the quality of care given to Medicare patients.
Service quality: An MCO's success in meeting the nonclinical customer service needs and expectations of plan members.
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