Ch 2 The Health Care Environment

Health Maintenance Organization (HMO)

• Health insurance plan that allows you to see any doctor, anytime.  Usually has a copayment and is cheaper if you use in-network doctors.
• Health insurance plan that requires you to work with a primary care physician to manage you care.  Also  require you to use in-network services.
• Health insurance plan that combines elements of HMO and PPO. You can use a Primary Care Physician or direct your own care.

Preferred Provider Organization (PPO)

• Plan that requires you to work with a primary care physician who will direct your care.  Requires you to use in-network providers.
• Plan that combines elements of PPO and HMO.  You can use a primary care physician or direct your own care.
• Plan allows you to see any doctor at anytime.  Usually has a co-payment and is cheaper if you use in-network providers.

Managed Care

• Services designed to keep you healthy.Usually provided at no cost to the consumer.
• Health problem that existed before the date your insurance became effective.
• Way a healthcare system manages its costs and uses its resources.

managed care plans

• HMO
• PPO
• BOTH
• NONE

Managed Care

• Insurance plans designed specifically to control the cost of healthcare
• Also known as PPO
• Also known as HMO
• A referral to see a specialist

HMO

• Health Maintenance Organization
• Health Managed Organization
• Health Maintained Operation
• Health Managed Operation

PPO

• Preferred Plan Operation
• Preferred Provider Organization
• Preferred Practice Organization
• Preferred Participation Operation

Health Insurance

• Portion of the cost of service to be paid by the employer
• Protection against financial lost by unplanned health related events
• Treatments for conditions not covered by insurance policies
• Services rendered by providers

A 30 year woman broke her arm and went to the ER for treatment. Her health insurance plan has a $1,500 deductible. What does this mean

• She can deduct $1,500 from the hospital bill, but must pay the rest
• The hospital will only charge her $1,500
• She is resoponsible for paying, $1,500 of her medical expenses before her insurance starts to pay
• Her insurance company will only pay $1,500 and she must pay the rest

Managed care organizations may attempt to limit a patient's

• choice of hospitals.
• referrals to specialists.
• length of stay in a hospital.
• all of the above.